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

  1. Jonathan I Bisson1,*,
  2. Neil P Roberts1,2,
  3. Martin Andrew1,
  4. Rosalind Cooper2,
  5. Catrin Lewis1

Editorial Group: Cochrane Depression, Anxiety and Neurosis Group

Published Online: 13 DEC 2013

Assessed as up-to-date: 12 APR 2013

DOI: 10.1002/14651858.CD003388.pub4


How to Cite

Bisson JI, Roberts NP, Andrew M, Cooper R, Lewis C. Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD003388. DOI: 10.1002/14651858.CD003388.pub4.

Author Information

  1. 1

    Cardiff University School of Medicine, Institute of Psychological Medicine and Clinical Neurosciences, Cardiff, UK

  2. 2

    Cardiff and Vale University Health Board, Psychology and Counselling Direcorate, Cardiff, UK

*Jonathan I Bisson, Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Hadyn Ellis Building, Maindy Road, Cardiff, CF24 4HQ, UK. bissonji@cardiff.ac.uk. jon.bisson@btinternet.com.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 13 DEC 2013

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Characteristics of included studies [ordered by study ID]
Adenauer 2011

MethodsRandomised controlled trial


Participants34 refugees (in Germany) with a history of violence and persecution, suffering PTSD (15 women, 19 men)


Interventions12 sessions of Narrative Exposure Therapy (NET) (n = 16) vs waitlist control (n = 18) in parallel


OutcomesCAPS, HDRS, ssVEF


NotesExperienced therapists delivered therapy. Treatment adherence was not assessed, but monitored in supervision sessions.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Participants that fulfilled the inclusion criteria were randomized into the two groups using a computer-generated list of random numbers".

Allocation concealment (selection bias)Unclear riskComment: Allocation concealment was not reported.

Incomplete outcome data (attrition bias)
All outcomes
High riskQuote: " As this study focuses on brain changes through psychotherapy rather than examining the clinical efficacy of the treatment, we restricted all analyses to the sample of study completers". Drop-out rates were one participant from treatment and two from waitlist, all due to deportation. Data for a further 4 participants were excluded from the treatment group, and another 8 from waitlist, due to no/poor-quality MEG data.

Selective reporting (reporting bias)High riskwww.clinicaltrials.gov-/ct2/show/NCT00563888 specified the CAPS as primary outcome and ssVEFs as secondary. The paper is written in terms of ssVEF as primary outcome. The paper trials register also specifies a 4- and 9-month follow-up.

Other biasHigh riskThere was a mean difference of 16 points in pretreatment CAPS scores between the two groups (NET being greater).

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Two independent female masters-level psychologists, who were unaware of the patients’ treatment group, performed all assessments at pretreatment, posttreatment, and 3- and 6-month follow-up. The 12-month follow-up assessment was conducted via mail. Blindness was maintained by ensuring that the assessors had no access to group allocation and never talked with patients about which group they were in."

Asukai 2010

MethodsRandomised controlled trial


Participants24 individuals (Japanese) with DSM-IV PTSD after various traumas (21 women, 3 men)


Interventions8 - 15 90-minute sessions of Prolonged Exposre (TFCBT) (n = 12) sessions vs treatment as usual (TAU) (n = 12)


OutcomesCAPS, IES-R, CES-D, GHQ-28


NotesTherapists were masters level psychologists. TAU included pharmacotherapy. Baseline demographics were similar within both groups. The difference in scores between both groups was nonsignificant at baseline on any of the assessment scales. Treatment adherence was measured.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "randomized by the study site based on computer-generated random digit numbers by permuted blocks between 4 and 8."

Allocation concealment (selection bias)Unclear riskComment: Allocation concealment was not reported. Participants were randomised at the study site.

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "intention-to-treat analysis was performed to determine the relative effect between the two treatment groups for each periodic posttreatment assessment, and those between pre-PE (after the waiting period) and post-PE treatment in the control group (CAPS total score, IES-R, CES-D, and GHQ-28)."

Comment: 3 dropped out from TFCBT, and one from TAU. A reason was only reported for one of these drop-outs.

Selective reporting (reporting bias)Low riskComment: All specified and expected outcomes appear to have been reported.

Other biasLow risk Comment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Two independent female masters-level psychologists, who were unaware of the patients’ treatment group, performed all assessments at pretreatment, posttreatment, and 3- and 6-month follow-up. The 12-month follow-up assessment was conducted via mail. Blindness was maintained by ensuring that the assessors had no access to group allocation and never talked with patients about which group they were in."

Basoglu 2005

MethodsRandomised controlled trial


Participants59 earthquake survivors in Turkey with DSM-IV PTSD (50 women, 9 men)


InterventionsSingle session of CBT (n = 31) vs waitlist control (n = 28)


OutcomesCAPS, TSSC, FAQ, BDI, WSA


NotesTreatment delivered by psychologists trained in the approach. Treatment adherence was measured.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Random allocation was conducted according to a computer-generated randomization list. Blocking was used to ensure approximately equal cell sizes."

Allocation concealment (selection bias)Low riskQuote: "The participants were recruited into the study by four independent assessors, who did not have access to the random assignment schedule. The latter was implemented by the project coordinator, who did not take part in the assessments at any stage during the trial."

Incomplete outcome data (attrition bias)
All outcomes
High riskQuote: "As a result of case attrition after week 6, two types of end-point imputation analyses were carried out. First, the treatment effects were examined at each follow-up, carrying forward the scores of the non-improved non-completers at their last available assessment to subsequent follow-up points. As this procedure did not involve the improved non-completers and assumed that the non-improved non-completers would have remained non-improved had they stayed in the study, it led to a conservative analysis of the treatment effects."

Comment: participants who did not have at least one follow-up after treatment were replaced. Eight individuals dropped out of treatment group and 2 from waitlist. No reasons were given.

Selective reporting (reporting bias)Low riskComment: All specified and expected outcomes appear to have been reported.

Other biasLow riskComment: Baseline demographics are poorly reported. Groups were reported to be similar in every baseline variable but gender (only 1 man in WL group vs 8 in the treatment group).

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote "The assessments were conducted by four independent assessors (three psychologists and one psychiatrist), who were blind as to the participants’ experimental condition. A Blindness Integrity Assessment Form was used to elicit information about whether assessor blindness was maintained at the second assessment and the assessor’s guess as to the study participant’s experimental condition."

Basoglu 2007

MethodsRandomised controlled trial


Participants31 earthquake survivors in Turkey with DSM-IV PTSD (27 women, 4 men)


InterventionsSingle session of CBT (n = 16) vs repeated assessments (n = 15)


OutcomesCAPS, FAQ, BDI, WSA, GIS-S, GIS-A


NotesTreatment was delivered by therapists who were experienced in delivering the intervention on the basis of having done so as part of earlier trials.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote "A computer-generated sequence of random numbers that ensured equal cell sizes and did not lead to allocation of more than two consecutive cases to the same experimental condition was used in the randomization."

Allocation concealment (selection bias)Low riskQuote "Participants were enrolled by two independent assessors (psychologists) and randomizations was conducted by the second author, who did not participate in baseline assessments."

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: Participants who did not have at least one follow-up after treatment were replaced. ITT analyses were performed after this point. One person dropped out of treatment group. No one dropped out from waitlist group. No reasons were given.

Selective reporting (reporting bias)Low riskComment: All specified and expected outcomes appear to have been reported.

Other biasHigh riskComment: Treatment adherence was not assessed, since the treatment was said to closely reflect the way treatment was delivered in routine fieldwork. Poor reporting of baseline characteristics.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
High riskQuote: "The assessors were blind as to the participants’ experimental condition at the week 4 and week 8 assessments."

Test of blinding included. However, 6 cases were followed up by therapists due to an unexpected shortage of funding.

Beck 2009

MethodsRandomised controlled trial


Participants44 motor vehicle accident survivors (in the USA) with DSM-IV PTSD (36 women, 8 men)


InterventionsGroup TFCBT (n = 17) vs minimum contact (n = 16)


OutcomesCAPS, IES-R, BAI, BDI, ODI, PS-MPI


NotesExperienced therapists. Treatment adherence was assessed, as was competence.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote "Groups of four to seven individuals were formed as participants became eligible; a given group then was randomly assigned to either GCBT or MCC conditions."

Comment: Method used to generate the allocation sequence is not described in sufficient detail to assess the probability that it would produce comparable groups.

Allocation concealment (selection bias)Unclear riskQuote "Groups of four to seven individuals were formed as participants became eligible; a given group then was randomly assigned to either GCBT or MCC conditions."

Comment: There is no mention of any measures taken to conceal allocation

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: Completers data were analysed. 7 individuals dropped out of the treatment group and 2 from minimum contact. No reasons were given for drop-out.

Selective reporting (reporting bias)Low riskAll specified outcomes appear to have been reported, although results are discussed in terms of completers.

Other biasLow risk Comment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote "Interviews for the POST and FU assessments were administered by an individual who had not conducted the pre-treatment assessment and was unaware of patients' treatment status and their time of assessment (POST versus FU)."

Bichescu 2007

MethodsRandomised controlled trial


Participants18 former political detainees (in Romania) with PTSD (17 men, 1 woman)


InterventionsNarrative Exposure Therapy (n = 9) vs psychoeducation (n = 9)


OutcomesCIDI, BDI


NotesAll treatment carried out by a PhD psychology student. Unclear whether adherence was measured, but supervision was provided by email.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskQuote: "Participants were assigned through a random selection procedure of participants name-cards to one of two treatment groups: NET and PED."

Comment: It is unclear how exactly this was performed.

Allocation concealment (selection bias)Unclear risk Comment: The authors do not report any methods of allocation concealment.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: No drop-outs.

Selective reporting (reporting bias)Low riskComment: All specified and expected outcomes appear to have been reported.

Other biasHigh risk Comment: Very small sample size

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Our intent was to perform a blinded assessment by keeping the interviewers unaware of the treatment condition and pre-test scores of the individual patients and by instructing the patients not to inform the interviewers about their treatment. However, due to the large differences in procedures and number of sessions between the two treatment conditions, it was not possible for us to achieve complete blindness in all cases. Occasionally, a patient revealed details about his treatment that might have affected the blindness of the interviewer."

Blanchard 2003

MethodsRandomised controlled trial


Participants98 road traffic accident survivors in the USA (72 women, 26 men)


Interventions8 - 12 sessions TFCBT (n = 27) vs 8 - 12 sessions supportive psychotherapy (n = 27) vs waiting list (n = 24) (all three arms included in meta-analyses)


OutcomesIES,STAI


NotesTherapists were practising psychologists, with over 5 years experience. Each had a cognitive behavioural orientation, but treated participants in both active treatment arms. Adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskQuote "The senior author matched participants into triads, based on the CAPS score and diagnosis,and then randomly assigned triads to a therapist and to conditions within the triad."

Comment: Indicates that the method of sequence generation poses the potential for bias.

Allocation concealment (selection bias)Unclear riskComment: there were no reported measures of allocation concealment.

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote "When we could not obtain dropout assessment data, we substituted the initial assessment data in the intent to treat analysis." However, no reasons were reported for drop-outs (10 from CBT, 9 from supportive psychotherapy, and 1 from waitlist).

Selective reporting (reporting bias)Low riskComment: All specified and expected outcomes appear to have been reported.

Other biasLow riskComment: no other sources of bias detected.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote "The assessors were kept blind to treatment condition."

Brom 1989

MethodsRandomised controlled trial


Participants112 outpatients in the Netherlands. Various traumas, 89 bereaved. (88 women, 24 men)


Interventions14 - 18 sessions of trauma desensitisation (n = 31), hypnotherapy (n = 29), psychodynamic therapy (n = 29) or waiting list (n = 23) (data could not be entered into meta-analysis, included only intrusion and avoidance sub-scales)


Outcomes"trauma symptoms" on SCL-90


NotesTherapists with over 10 years experience in the specific method. Therapists conducted the therapies they preferred outside the research setting (i.e. there were different therapists treating each treatment arm). Supervision sessions ensured adherence.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation is not reported. It is simply stated that treatment assignment was random.

Allocation concealment (selection bias)Unclear risk Comment: The method of sequence allocation is not reported,

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: There were no reported reasons for drop-out. There was inadequate statistical correction for these drop-outs.

3 individuals dropped out of each of the treatment arms.

Selective reporting (reporting bias)Unclear riskQuote: "We focus in this article on the data from the standardized questionnaires, disregarding the physiological and behavioral tests that were administered. The domains that were covered by the questionnaires were general symptoms, symptoms of the coping process, and personality."

Comment: It is unclear whether it had originally been the intention to report the behavioural tests.

Other biasHigh riskComment: Inadequate reporting of baseline characteristics. Each treatment arm had its own dedicated therapists (i.e. differences in outcome may have been attributable to expertise as opposed to the intervention).

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskComment: There is no mention of blinding outcome assessors.

Bryant 2003

MethodsRandomised controlled trial


Participants58 outpatient survivors of non-sexual assaults or road traffic accidents in Australia (30 women, 28 men)


Interventions8 weekly 90-minute sessions of imaginal exposure (n = 20), imaginal exposure/cognitive restructuring (n = 20) or supportive counselling (n = 18). (imaginal exposure and imaginal exposure/cognitive restructuring were combined for meta-analysis).


OutcomesCAPS, IES, STAI, BDI


NotesTherapists were masters level clinical psychologists. Treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Randomization was conducted by a process of minimization stratified on gender, trauma type, and PTSD total score. Participants were randomly assigned according to a random numbers system and each month Richard A. Bryant amended the allocation to ensure that gender, trauma type, and PTSD severity were balanced across conditions."

Allocation concealment (selection bias)Unclear riskComment: It is unclear if/how allocation was concealed.

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote "Intent-to-treat values were devised by using a last-value-carried forward procedure to provide data for missing values that occurred because of dropout."

Comment: Reasons for drop-out are not fully reported. ITT analyses were however reported. Drop-out by group was as follows: imaginal exposure (5), imaginal exposure/cognitive restructuring (5) or supportive counselling (3).

Selective reporting (reporting bias)Low riskComment: All specified and expected outcomes appear to have been reported.

Other biasLow riskComment: no other sources of bias detected.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Initial assessments were conducted at pretreatment, posttreatment, and 6-month follow-up by independent clinicians who were unaware of the treatment condition of participants. Blindness was maintained by ensuring that clinicians who conducted assessments did not have access to (a) participant notes, (b) treatment allocation of participants, or (c) supervision discussions of therapy sessions."

Bryant 2011

MethodsRandomised controlled trial


Participants28 survivors of terrorist attacks in Southern Thailand (27 women, 1 man)


Interventions8 weekly 60-minute sessions of CBT (n = 16) vs TAU (n = 12)


OutcomesPSS, BDI, ICG


NotesTherapy was conducted by Thai psychologists or psychiatric nurses who were trained to use the treatment manual in 3 2-day workshops occurring over 12 months. They had no previous experience of CBT. During the trial itself, therapists conducted treatment without formal supervision. TAU comprised the equivalent number of sessions of supportive counselling being provided by psychiatrists who were not trained in CBT. Adherence was not assessed, but checklists indicated components of treatment completed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Patients were randomised according to a random numbers system administered by health officials in Bangkok (fully independent of counsellors and the study co-ordinator)."

Allocation concealment (selection bias)Low riskQuote: "Patients were randomised according to a random numbers system administered by health officials in Bangkok (fully independent of counsellors and the study co-ordinator)."

Comment: Allocation was independent and remote from study site.

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "There were no treatment drop-outs, and so analyses focus on all patients who were randomised into the study."

Selective reporting (reporting bias)Low riskComment: All specified and expected outcomes appear to have been reported.

Other biasHigh riskRecruitment was terminated prematurely due to health workers being targeted by the terrorists.

Small sample size (n = 28)

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Assessments conducted at post-treatment and 3 months following treatment were conducted by independent personnel unaware of patients’ treatment condition."

Carlson 1998

MethodsRandomised controlled trial


Participants35 men with combat-related PTSD in Hawaii


Interventions12 bi-weekly sessions of 60-75 minutes EMDR (n = 10) vs 40 minutes biofeedback-assisted relaxation vs routine care (n = 13) vs TAU (n = 12) (all interventions included in meta-analysis)


OutcomesMississippi PTSD scale, IES, STAI, BDI


NotesExperienced therapists


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: The method of allocation concealment (if any) was not reported.

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: There was 1 drop-out from the biofeedback-assisted relaxation. There was no reason given for this drop-out. These were not properly accounted for in terms of statistical tests.

Selective reporting (reporting bias)Low riskComment: All specified and expected outcomes appear to have been reported. The CAPS is emphasised as the primary outcome measure throughout.

Other biasUnclear risk Comment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
High riskComment: Assessors were not blind, although a second CAPS was administered by a blind assessor.

Chard 2005

MethodsRandomised controlled trial


Participants71 female child sexual abuse survivors in the USA


Interventions17 weekly 90-minute group sessions of cognitive processing therapy for sexual abuse survivors and a 60-minute individual session for first 9 weeks and 17th week (n = 36) vs minimal attention (weekly 5 to 10-minute phone call providing supportive counselling) (n = 35)


OutcomesCAPS, MPSS, BDI-II, DES-II


Notes Experienced therapists delivered therapy and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: The method of allocation concealment (if any) was not reported.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses were conducted. No reasons were given for withdrawals from the study (8 in the treatment arm and 7 from the minimal-attention group.)

Selective reporting (reporting bias)Unclear riskComment: All specified and expected outcomes appear to have been reported.

Other biasLow risk Comment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Research assistants blind to the assigned condition of the subject conducted all interviews, and treatment completers were asked not to mention having been in therapy at posttreatment assessments."

Cloitre 2002

MethodsRandomised controlled trial


Participants58 female child sexual abuse survivors in the USA


Interventions16 bi-weekly sessions of 1½ hours of prolonged exposure and affect regulation (n = 22) vs waitlist (n = 24)


OutcomesCAPS, BDI, STAI


NotesExperienced therapists. Treatment adherence measured.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: The method of allocation concealment (if any) was not reported.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: There was a relatively high drop-out rate (9 from active treatment, 3 from the waitlist). There were no reasons given for drop-outs, but there were said to be no sociodemographic, clinical or symptom differences between completers and drop-outs. ITT analyses were performed

Selective reporting (reporting bias)High riskThere is emphasis on reporting improvements in affect regulation and interpersonal skills as opposed to PTSD symptoms. The Methods section does not seem to indicate that these were the primary outcome measures.

Other biasLow risk Comment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Clinician raters were blind to treatment condition at pre- and posttreatment."

Cloitre 2010

MethodsRandomised controlled trial


Participants104 female child sexual abuse survivors in the USA


InterventionsSTAIR/exposure vs support/exposure vs STAIR/support


OutcomesCAPS, PSS-SR, negative mood regulation scale, BDI, STAI, Inventory of Interpersonal Problems, Interpersonal Support Evaluation List


NotesTreatment was delivered by doctoral level psychologists, who had been trained by leading experts in the field. Adherence was measured.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Low riskQuote "Randomization blocks of nine (three instances of each of the three conditions) were employed, generated by an individual not otherwise involved with the study. Within each randomly assigned condition, the participant was assigned to one of three therapists, based on a match in availability."

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "Analyses for all symptom outcome measures were performed on the intent-to-treat sample using data from all participants according to their randomizations assignment. Missing data were imputed using PROC MI in SAS (SAS Institute, Cary, N.C.) to generate 10 imputed data sets."

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasLow risk Comment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskComment: Assessors were blinded.

Cooper 1989

MethodsRandomised controlled trial


Participants16 male Vietnam War veterans in the USA. All DSM-III PTSD


Interventions6 - 14 90-minute flooding sessions plus standard treatment (n = 8) vs standard treatment (n = 8)


OutcomesSTAI, BDI


NotesNo information was provided with regards to the therapists delivering treatment or any measures of treatment adherence.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskQuote: "Efforts were made to preclude bias in assessment by maintaining as nearly random a procedure as possible"

Comment: There were no details of the method of sequence generation, but the authors indicate that it was not entirely random.

Allocation concealment (selection bias)High riskQuote: "In all cases group assignment was pre-decided before the participant agreed to participate...there were three exceptions to the rule of pre-determined random assignment"

Comment: Allocation does not seem to have been concealed.

Incomplete outcome data (attrition bias)
All outcomes
High riskAll 16 participants provided posttreatment data, but 2 were removed from the analysis of data from the experimental group due to not completing therapy (1 from each group). These individuals were said to have a more severe presentation.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: Very small sample.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskSelf-report measures only, but it is not clear how these were administered.

Devilly 1998

MethodsRandomised controlled trial


Participants51 male combat veterans with DSM-III-R PTSD in Australia


Interventions12 sessions of EMDR (n = 19) vs biofeedback-assisted relaxation (n = 16) vs routine clinical care (n = 16) (all interventions included in meta-analyses)


OutcomesMississippi scale, PTSD symptom scale, IES, STAI, BDI


NotesTherapist trained by Francine Shapiro. No mention of an assessment of treatment adherence.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: There were no reasons given for drop-outs (6 drop-outs from EMDR, 4 drop-outs from relaxation and 6 drop-outs from usual care). Data from the completers were analysed.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported,

Other biasLow riskThere were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskComment: All measures were self-reported and administered by post.

Devilly 1999

MethodsRandomised controlled trial


Participants32 participants with DSM-IIIR PTSD (11 men, 21 women) in Australia


Interventions8 sessions EMDR (n = 17) vs 9 sessions TFCBT (n = 15) in parallel.


OutcomesBDI, SCL-90 Global distress, CMS, IES, PSS-SR, PTSD Interview (DSM-III-R)


NotesTherapists were appropriately trained and experienced. Treatment adherence was measured.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskQuote: "Participants were assigned to their experimental group using a stratified randomization technique: the first 10 referrals were assigned to the TTP condition (after a 50% chance of either TTP or EMDR) and the following 10 were assigned to the EMDR condition. This was done in order to consolidate therapist skills in each protocol and offset cross-pollination of the two, different, therapeutic protocols. Subsequently, subjects were assigned alternatively to the two conditions until a full cohort was obtained in each condition."

Allocation concealment (selection bias)Unclear riskComment: It is unclear whether any measures were in place for concealing allocation.

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: Only the data of completers were included in analyses.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: There were differences in the baseline characteristics of the two groups, for example, medication profiles (which were continued through the course of the trial).

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskComment: It is unclear whether outcome assessors were blinded.

Duffy 2007

MethodsRandomised controlled trial


Participants58 participants mostly resulting from the troubles in Northern Ireland (23 women, 35 men)


Interventions12 weekly sessions of cognitive therapy (n = 29) vs waiting list (n = 29). Cross-over trial.


OutcomesPDS, BDI, SDS


NotesExperienced therapists (1 social worker, 1 psychiatrist, and 3 nurse therapists). Treatment adherence does not seem to have been assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported. Participants were randomised remotely.

Allocation concealment (selection bias)Low riskQuote: "An independent office allocated patients to immediate therapy or to wait followed by therapy on a stratified random basis using the minimisation method of Pocock. Assessors were not aware of the allocation algorithm".

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "We carried out analyses on an intention to treat basis". Reasons for drop-out were reported (9 from cognitive therapy and 3 from waiting list).

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported,

Other biasHigh risk Treatment adherence was not measured.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskComment: Measures were self-reported, but it is unclear how these were administered.

Dunne 2012

MethodsRandomised controlled trial


Participants26 adults (13 men, 13 women) with chronic motor vehicle collision PTSD with chronic whiplash-associated disorders, in Australia


Interventions10 weekly sessions of TFCBT (n = 13) vs waiting list (n = 13)


OutcomesSCID-PTSD, PDS, IES-R, DASS, SF-36


NotesComment: All therapy delivered by 1 psychologist with 12 months experience of delivering TFCBT. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: Reasons for leaving the study were fully reported, ITT analyses were performed. Appropriate methods of imputing data were used. One participant dropped out of the treatment group and 2 from the waitlist group. Reasons for attrition were not fully reported.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: All therapy delivered by 1 psychologist with 12 months experience of delivering TFCBT. It is unclear whether or not treatment adherence was assessed.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskComment: It is unclear whether the outcome assessor was blind.

Echeburua 1997

MethodsRandomised controlled trial


Participants20 female sexual aggression survivors in Spain


Interventions6 weekly sessions of graded self exposure (n = 10) vs relaxation therapy (n = 10)


OutcomesGlobal PTSD scale, STAI, BDI


NotesTreatment delivered by an experienced clinical psychologist. Treatment adherence was not measured.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: No drop-outs.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: Small sample size. Treatment adherence was not measured.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskComment: It is unclear whether assessors were blinded.

Ehlers 2003

MethodsRandomised controlled trial


Participants69 participants with duration of PTSD greater than 3 months from a larger RCT of 85 participants with DSM-IV PTSD in the UK. Various traumas.


Interventions12 x weekly sessions of CT (n = 22) vs repeated assessment (n = 20) vs self help (n = 27) (CT and repeated assessment included in a meta-analysis).


OutcomesCAPS, PDS, BDI, BAI


NotesTherapist details/credentials are not reported and it is unclear whether treatment adherence was measured.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "Randomization was stratified by sex and severity of PTSD symptoms using the random permuted blocks within strata algorithm."

Comment: The method of random sequence generation was not reported.

Allocation concealment (selection bias)Low riskQuote: "Assessors who decided whether patients were suitable for inclusion in the study could not predict what treatment condition would be assigned to the patient, as (1) the allocation list was kept locked in a separate central office and the patient’s allocation was only revealed 3 weeks later, following the self-monitoring assessment, and (2) the study was conducted at 2 sites."

Incomplete outcome data (attrition bias)
All outcomes
High riskQuote: "As the most conservative estimate of the efficacy of CT, we report a completer analysis for the continuous outcome measures, comparing the full sample of patients allocated to CT (as there were no dropouts) with the completers in the SH and RA
conditions." There were three drop-outs from self help and two from repeated assessment. Reasons for drop-outs were fully reported.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: Therapist details/credentials are not reported and it is unclear whether treatment adherence was measured.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Independent assessors (trained clinical psychologists or research nurses) who were not aware of the treatment condition gave the Clinician-Administered PTSD Scale (CAPS-SX) interview."

Comment: There was a test of blinding.

Ehlers 2005

MethodsRandomised controlled trial


Participants28 individuals with DSM-IV PTSD in the UK. Various traumas.


Interventions12 x weekly sessions of CT (n=14) vs WL (n=14)


OutcomesCAPS, PDS, BDI, BAI


NotesTherapist details/credentials are not reported and it is unclear whether treatment adherence was measured.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "Patients were randomly allocated to either immediate cognitive therapy"

Comment: The method of randomisation is clear.

Allocation concealment (selection bias)Unclear riskComment: The method of allocation concealment was unclear.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses were performed.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: Therapist details/credentials are not reported and it is unclear whether treatment adherence was measured.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: Independent assessors were used.

Fecteau 1999

MethodsRandomised controlled trial


Participants23 road traffic accidents in Canada. 14 women, 6 men completed the study. It is unclear how many men and women entered the study originally


Interventions8 - 10 hours CBT (n = 12) vs waitlist (n = 11)


OutcomesCAPS, IES, BDI, BAI


NotesExperienced therapists delivered therapy and treatment adherence was assessed


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "participants were then randomly assigned to the treatment or WLC groups by the flip of a coin".

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: 2 participants dropped out of the treatment group and 1 dropped off the waitlist. Reasons for attrition are reported. Only the data of completers are included in the analysis.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported, although the lack of effect on the measure of depression is not divulged in the abstract.

Other biasHigh riskComment: Small sample size.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskComment: Outcome measures were rated by an "independent assessor".

Feske 2008

MethodsRandomised controlled trial


Participants27 low-income African-Americans with complex trauma histories and


Interventions9 - 12 weekly sessions of PE vs 9 - 12 sessions of non-TF supportive counselling DSM-IV PTSD


OutcomesPTSD Diagnostic Scale, BDI, BAI, BSQ, Anger Expression Inventory, Brief Symptom Inventory


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: Drop-outs reported (2 for unknown reasons).

Completers Analysis.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: Small sample size.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskComment: It is unclear whether outcome assessors were blinded.

Foa 1991

MethodsRandomised controlled trial


Participants55 female rape victims in the USA. All DSM-IIIR PTSD


Interventions9 1½-hour sessions of prolonged exposure (n = 14) vs stress inoculation training (n = 17) vs supportive counselling (n = 14) vs waiting list (n = 10) control (all interventions included in meta-analyses).


OutcomesPTSD severity, BDI, STAI


NotesExperienced therapists delivered therapy and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
High riskQuote: "Subsequent analyses were conducted on data from the 45 completers."

Comment: 10 participants dropped out of treatment (prolonged exposure (4) vs stress inoculation training (3) vs supportive counselling (3) vs waiting list control (0)). No reasons reported for drop-outs.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasLow riskComment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Assessments at pre-treatment, posttreatment, and follow-up consisted of clinical interviews conducted by an independent assessor, who was blind to treatment conditions, and self report questionnaires"

Foa 1999

MethodsRandomised controlled trial


Participants96 female sexual assault victims (69 sexual assault) in the USA


Interventions9 sessions (2 x 2 hours, 7 x 1½ hours) prolonged exposure (n = 25) vs stress inoculation training (n = 26) vs combination PE-SIT (n = 30) vs waiting list (n = 15) (all interventions included in meta-analyses).


OutcomesPSS-I, BDI, STAI


NotesExperienced therapists delivered therapy and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses performed. 17 participants dropped out of treatment (2 from prolonged exposure, 7 from SIT and 8 from PE-SIT).

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh risk Comment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Independent evaluators... were unaware of treatment assignment".

Foa 2005

MethodsRandomised controlled trial


Participants171 female sexual assault survivors in the USA


Interventions9 - 12 weekly 90- to 120-minute sessions of prolonged exposure (n = 79) vs 9 - 12 weekly 90- to 120-minute sessions of prolonged exposure and cognitive restructuring (n = 74) vs waiting list (n = 26) (all interventions included in meta-analyses).


OutcomesPSS-I, BDI, SAS


NotesExperienced therapists delivered therapy and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "The study statistician assigned participants who provided informed consent to one of the three conditions using a weighted randomizations procedure such that participants were assigned to one of the active treatment conditions at a greater rate than to WL."

Comment: Although reported to be carried out by a statistician, the method of sequence generation is unclear.

Allocation concealment (selection bias)Low riskQuote: "The study statistician assigned participants who provided informed consent to one of the three conditions using a weighted randomizations procedure such that participants were assigned to one of the active treatment conditions at a greater rate than to WL."

Comment: Participants were assigned to a group by an external person.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses were performed. Reasons for drop-out were not fully reported. There were many drop-outs (1 from waiting list, 30 from PE/CR and 27 from PE).

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported

Other biasLow risk Comment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "All evaluations were conducted by trained doctoral or master’s level CTSA clinicians who were blind to study condition."

"Participants were instructed by their therapists and the evaluators to not reveal any information that might unblind the evaluator to treatment condition."

Forbes 2012

MethodsRandomised controlled trial


Participants59 veterans (57 men) with military-related PTSD in Australia


Interventions12 sessions of cognitive processing therapy (n = 30) vs treatment as usual (n = 29)


OutcomesCAPS, PCL, BDI-II, STAI-State, DAR-7, AUDIT, PTCI, ADAS, WHOQOL


NotesExperienced therapists delivered therapy and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of random sequence generation was not reported.

Allocation concealment (selection bias)Low riskComment: A central method of allocation was employed.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: Reasons for leaving the study were fully reported, ITT analyses were performed. Appropriate methods of imputing data were used. 9 participants dropped out of each group. Reasons for attrition are not fully reported.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: Different therapists provided CPT and TAU.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskQuote: "All assessments were conducted by an independent clinical assessor blind to allocation and treatment. To maintain blindness at post-treatment and 3 month follow-up appointments the participants were reminded not to reveal what treatment they had received."

Galovski 2012

MethodsRandomised controlled trial (cross-over)


Participants100 individuals (unclear how many were men and women) with PTSD after sexual or physical assault in childhood or adulthood in the USA


InterventionsCPT (n = 47) vs symptom monitoring delayed treatment (n = 53)


OutcomesCAPS, BDI-II, TRGI, QOLI, SF-36


NotesExperienced therapists delivered therapy and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: 7 participants dropped out of symptom monitoring delayed treatment and 14 dropped out of CPT. The reason for drop-out was unknown in 50% of cases. ITT analyses were performed.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasLow riskComment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Posttreatment and follow-up assessments were conducted by raters blind to both randomization and dropout status."

Gamito 2010

MethodsRandomised controlled trial


Participants10 male war veterans of the Portugese Colonial War between 1963 and 1970 with DSM-IV PTSD


InterventionsVirtual reality exposure (n = 5) vs exposure in imagination versus WL (n = 3) vs exposure in imagination (n = 3) in parallel


OutcomesCAPS, IES


NotesComment: It is unclear who delivered the therapy


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "The participants were randomly assigned to three study groups".

Comment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: There was 1 drop-out (from virtual reality exposure) without a reason. It is unclear how these missing data were handled.

Selective reporting (reporting bias)High riskComment: Improvements in depression and anxiety were emphasised, despite measures of PTSD being indicated as the primary outcome measure.

Other biasHigh riskVery small sample size. It is unclear who delivered the therapy. Treatment adherence was not measured. Baseline characteristics are poorly reported. The issue of researcher allegiance cannot be ruled out.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskComment: It is unclear whether outcome assessors were blinded.

Gersons 2000

MethodsRandomised controlled trial


Participants42 police officers. DSM-IIIR PTSD. Various workplace traumas (5 women, 37 men) in the Netherlands


Interventions16 x 60-minute sessions of brief eclectic therapy (n = 22) vs wait list (n = 20) in parallel


OutcomesSI-PTSD, SCL-90


NotesExperienced therapists delivered therapy. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses were conducted. Only 1 participant dropped out, from the waitlist. A reason was given for this individual leaving the study.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh risk Comment: The issue of researcher allegiance cannot be ruled out.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "All assessments were performed by one of three independent assessors".

Hensel-Dittmann 2011

MethodsRandomised controlled trial


Participants28 asylum seekers who had experienced war and torture


InterventionsNarrative Exposure Therapy (n = 15) vs Stress Innoculation Therapy (n = 13)


OutcomesCAPS, HAM-D


Notes Experienced therapists delivered therapy and treatment adherence was assessed


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Subjects were randomly assigned to either NET or SIT. Participants were matched pairwise according to gender, age, and region of origin and were then allocated to NET or SIT by flipping a coin."

Allocation concealment (selection bias)Low riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "Aiming at an intention-to-treat analysis, all subjects who were randomised were included in the outcome analysis. Much of the recent literature indicates that last-observation- carried-forward procedures may produce seriously biased results. Hence we used mixed effects models."

Comment: There were 3 drop-outs from TFCBT and 2 from non-TFCBT.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasLow riskComment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote "We aimed to keep the assessors blind to the treatment conditions of the subjects;
however, occasionally the treatment condition was revealed to the rater by responses from the patient."

Hinton 2005

MethodsRandomised controlled trial


Participants40 treatment-resistant Cambodian refugees with comorbid panic attacks (24 women, 16 men)


Interventions12 weekly sessions of CBT (n = 10) vs delayed treatment (n = 10)


OutcomesCAPS, ASI, N-PASS, O-PASS, N-FSS, O-FSS, SCL


NotesExperienced therapists delivered therapy. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "All randomised patients completed the study, and there were no missing data."

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasLow risk Comment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Blind to treatment condition, all assessments were made by a Cambodian bicultural worker (D.C., V.P.) with over 2 years of mental health experience."

Hinton 2011

MethodsRandomised controlled trial


Participants24 Latino women with treatment-resistant PTSD


Interventions14 weekly sessions of TFCBT (n = 12) vs applied muscle relaxation (n = 12)


OutcomesPTSD checklist, nervios scale, emotion regulation scale, SCL anxiety scale


NotesExperienced therapists delivered therapy. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: There were no drop-outs.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskSmall sample size.

Participants continued medication and supportive therapy. Details were not reported.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskSelf-report questionnaires were used, but not clear how they were administered

Hogberg 2007

MethodsRandomised controlled trial


Participants24 transportation workers with DSM-IV PTSD (19 men, 5 women) in Sweden.


InterventionsEMDR (n = 13) vs waitlist (n = 11)


OutcomesGAF, HAM-A, HAM-D, IES, BAI


NotesExperienced therapists delivered therapy and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote "The randomisation was done by picking a sealed ballot in the presence of a research nurse who coordinated the study and followed the participants through all phases."

Allocation concealment (selection bias)Unclear riskComment: The method of random sequence generation was not reported.

Incomplete outcome data (attrition bias)
All outcomes
High riskQuote: "We decided not to use an intention to treat analysis because there were no drop-outs during EMDR".

Comment: 2 individuals dropped out of the waitlist group.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: Small sample size.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "by a psychiatrist not otherwise engaged in the study and blind to the experimental condition of the participants."

Hollifield 2007

MethodsRandomised controlled trial


Participants84 individuals with DSM-IV PTSD, various traumas in the USA


InterventionsCBT (n = 28) vs acupuncture (n = 29) vs WL (n = 27) (CBT and WL included in a meta-analysis).


OutcomesPSS-SR, HSCL-25, Sheehan Disability Scale


NotesThere were no reported assessments of treatment fidelity, and little information about the individuals who delivered the treatments.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: “before enrolling participants, 90 study ID numbers were pre-randomized using a computerized random numbers procedure without restrictions. This allocation procedure was concealed from clinicians.”

Allocation concealment (selection bias)Low riskQuote: “before enrolling participants, 90 study ID numbers were pre-randomized using a computerized random numbers procedure without restrictions. This allocation procedure was concealed from clinicians.”

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses were performed using acceptable methods. Reasons for withdrawal were fully reported (10 from acupuncture, 7 from CBT and 27 from wait list).

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: Each intervention was delivered by a single practitioner. There were no reported assessments of treatment fidelity, and little information about the individuals who delivered the treatments.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskSelf-report measures only.

Quote “The RC collected the data which were concealed from investigator/clinician.”

Ironson 2002

MethodsRandomised controlled trial


Participants22 victims of various traumas with DSM-IIIR PTSD (17 women, 5 men) in the USA


Interventions3 preparatory sessions followed by 1 - 3 sessions of EMDR (n = 10) or prolonged exposure (n = 12)


OutcomesPSS-SR, BDI


NotesExperienced therapists delivered therapy and treatment adherence was assessed. Therapists delivered both treatments.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses were performed. Reasons for drop-out were not fully reported (1 from EMDR, 6 from TFCBT).

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: Baseline characteristics are poorly reported. Small sample size.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
High riskComment: All measures were self report, but assessors were not blind.

Jensen 1994

MethodsRandomised controlled trial


Participants29 male Vietnam War veterans with PTSD in the USA


Interventions3 sessions of EMDR (n = 15) usually within 10 days vs usual care (n = 14)


OutcomesSI-PTSD


NotesExperienced therapists delivered therapy. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: Only the data of completers are included in the analysis. Reasons for drop-outs were not fully reported. 2 participants dropped out from each group.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: Small sample size. Baseline characteristic are poorly reported. Unclear whether treatment adherence was measured.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskComment: It is unclear whether outcome assessors were blinded.

Keane 1989

MethodsRandomised controlled trial


Participants24 male Vietnam War veterans with DSM-IIIR PTSD in the USA


Interventions14 - 16 sessions implosive (flooding) (n = 11) versus waiting list control (n = 13)


OutcomesPTSD subscale, BDI, STAI


NotesExperienced therapists delivered therapy. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskThere is emphasis in the reporting on those scales where improvements were evident.

Selective reporting (reporting bias)Unclear riskComment: Only the data of completers are included in the analysis. One participant dropped out of each group.

Other biasHigh riskComment: Small sample size. Poor reporting of baseline characteristics. Unclear whether or not treatment adherence was measured.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
High riskQuote: "therapists rated their own patients progress following treatment."

Kearney 2013

MethodsRandomised controlled trial


Participants47 veterans (37 men) with chronic PTSD in the USA


InterventionsMindfulness-Based Stress Reduction (MBSR) (n = 25) group intervention vs TAU (n = 22)


OutcomesPCL, PHQ-9, BADS, SF-8, FFMQ


NotesTherapist credentials/experience is not reported. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of random sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskQuote: "assessment subjects were randomized using concealed allocation to the intervention group" - precise methods of allocation concealment were not reported.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: Reasons for leaving the study were fully reported, ITT analyses were performed. Appropriate methods of imputing data were used. 2 participants dropped out from the treatment group and 1 from the waitlist.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: Therapist credentials/experience is not reported. It is unclear whether or not treatment adherence was assessed.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskThere is no mention of the blinding of assessors. Measures were self report.

Krakow 2000

MethodsRandomised controlled trial


Participants169 female sexual abuse survivors reporting nightmares at least once a week in the USA


Interventions3 sessions (2 x 3-hour 1 week apart and 1 x 1-hour follow-up 3 weeks later) of cognitive imagery rehearsal for nightmares (n = 87) vs waiting list (n = 82).


OutcomesNightmare Frequency Questionnaire, PSS, Pittsburgh Sleep Quality Index, Nightmare Effects Survey


NotesIt is unclear who delivered the intervention or whether or not treatment adherence was measured.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
High riskQuote: "The main analysis was conducted on the 91 completers". The drop-out rate was very high and reasons for leaving the study were not fully reported.

Selective reporting (reporting bias)High riskComment: Completer data were reported despite a very high drop-out rate.

Other biasHigh riskComment: The issue of researcher allegiance cannot be ruled out.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskComment: All measures were self-reported but it is unclear how these were administered.

Krakow 2001

MethodsRandomised controlled trial


Participants168 female sexual assault survivors. 95% DSM-IIIR PTSD in the USA


Interventions2 x 3-hour and 1 x 1-hour sessions of group imagery rehearsal (n = 88) versus waiting list (n = 80)


OutcomesPSS


NotesTherapist credentials/experience is not reported. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "To mask treatment assignment, patients mailed back a postcard after intake to complete entry into the protocol The postcard’s time and date were logged into a computer and entered into a previously generated list of numbers that randomly assigned participants to treatment and control groups. All numbers and group assignments were generated at the start of the protocol".

Comment: The method of sequence generation was not reported

Allocation concealment (selection bias)Low riskQuote: "To mask treatment assignment, patients mailed back a postcard after intake to complete entry into the protocol The postcard’s time and date were logged into a computer and entered into a previously generated list of numbers that randomly assigned participants to treatment and control groups. All numbers and group assignments were generated at the start of the protocol".

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses were performed. 20 withdrew from waitlist and 22 from the treatment group. Reasons for attrition are not fully reported.

Selective reporting (reporting bias)Low risk Comment: All specified outcomes were reported

Other biasHigh riskComment: The issue of researcher allegiance cannot be ruled out. Therapist credentials/experience is not reported. It is unclear whether or not treatment adherence was assessed.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote "To limit external bias, blinding occurred at 3 points of data collection:
(1) at intake, group assignment had not been established; (2) at 3-month follow-up, questionnaires were completed through the mail; and (3) at 6-month follow-up, interviewers were unaware of group status."

Kubany 2003

MethodsRandomised controlled trial


Participants37 female survivors of assault in Hawaii


Interventions8 - 11 bi-weekly 90-minute sessions of cognitive trauma therapy (n = 19) vs waitlist with delayed treatment (n = 18)


OutcomesCAPS, BDI


NotesLead author was therapist for all participants. It is unclear whether treatment adherence was addressed


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "After these assessments, the women were randomly assigned to either an Immediate or a Delayed CTT-BW condition."

Comment: The method of random sequence generation was not reported,

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses. 1 participant dropped out from the treatment group and 4 from the waitlist.

Selective reporting (reporting bias)Unclear risk Comment: All specified outcomes were reported.

Other biasHigh riskComment: The issue of researcher allegiance cannot be ruled out. Lead author originated CTT-BW and conducted all therapy.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "The assessors were blind to participants’ condition assignments."

Kubany 2004

MethodsRandomised controlled trial


Participants125 female survivors of assault in Hawaii


Interventions8 - 11 bi-weekly 90-minute sessions of cognitive trauma therapy (n = 63) vs waitlist (n = 62)


OutcomesCAPS, BDI


NotesExperienced therapists delivered therapy and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses. Data were only available for 84 participants posttreatment. 22 dropped out of waitlist and 18 from TFCBT.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: The issue of researcher allegiance cannot be ruled out.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskComment: Assessors were blinded

Lee 2002

MethodsRandomised controlled trial


Participants24 DSM-IV PTSD sufferers. Various traumas (11 women, 13 men) in Australia.


Interventions7 weekly 90-minute sessions of stress inoculation training with prolonged exposure (n = 12) vs EMDR (n = 12)


OutcomesSI-PTSD, IES, BDI


NotesExperienced therapists delivered therapy and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "There was random assignment to all conditions and multiple therapists were used to deliver each of the treatments."

Comment: The method of random sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "treatment non-completers were included in the analysis".

Comment: 3 participants dropped out from treatment, 1 from EMDR and one from stress management. It is unclear what group the third drop-out was in. Reasons for drop-out were not fully reported.

Selective reporting (reporting bias)Low risk Comment: All specified outcomes were reported.

Other biasHigh riskComment: Small sample size.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "assessments by a blind independent observer".

Lindauer 2005

MethodsRandomised controlled trial


Participants24 DSM-IV PTSD sufferers. Various traumas (11 men, 13 women) in the Netherlands


Interventions16 weekly 45- to 60-minute sessions of Brief Eclectic Psychotherapy (n = 12) vs waiting list (n = 12)


OutcomesSI-PTSD, HADS


NotesExperienced therapists delivered therapy and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "A colleague who had done no assessments used a computer program to randomly assign 12 patients to each condition in a block design."

Allocation concealment (selection bias)Low riskQuote: "A colleague who had done no assessments used a computer program to randomly assign 12 patients to each condition in a block design."

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "Intention-to-treat and per-protocol analyses were calculated."

Comment: 5 participants dropped out of the treatment group and 1 from the waitlist group. Reasons were fully reported.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: Small sample size.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation. The issue of researcher allegiance cannot be ruled out.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Each patient was assessed by a researcher (R.J.L.L. or E.P.M.M.), who were blind to all patients’ condition."

Marcus 1997

MethodsRandomised controlled trial


Participants67 DSM-IIIR PTSD. Various traumas. (53 women, 14 men) in the USA


InterventionsVariable number of 50-minute sessions of EMDR (n = 34) vs standard care (n = 33)


OutcomesIES, M-PTSD, BDI, STAI, SCL-90


NotesTherapists were psychologists with experience ranging from less than one year to over 18. It is unclear what experience the therapists delivering usual care had. There was no report of assessing treatment adherence.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: 1 participant dropped out of each group. It is unclear how this was handled.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: The usual care group, which included an array of interventions was not aimed at being optimally effective in terms of reducing symptom severity. There is little detail regarding the interventions offered as part of usual care and the credentials/experience of therapists delivering these interventions is not reported.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
High riskQuote: "It was not possible to keep the independent evaluator blind to the treatment condition".

Marks 1998

MethodsRandomised controlled trial


Participants87 DSM-IIIR PTSD, various traumas, in the UK


Interventions10 x 90-minute sessions of exposure (n = 23) vs cognitive restructuring (n = 19) vs exposure and cognitive restructuring (n = 24) vs relaxation therapy (n = 21) (the three exposure/cognitive-restructuring groups were combined).


OutcomesCAPS, IES, BDI, STAI


NotesExperienced therapists delivered therapy. Treatment adherence was assessed, as was homework compliance.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "analyses were also done on end-point imputed-scores carrying forward non-completers last available ratings".

Comment: There were drop-outs from each group: exposure (3) cognitive restructuring (1) exposure and cognitive restructuring (5) and relaxation therapy (1). Reasons for drop-out were not fully reported.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasLow riskComment: no other sources of bias detected.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "assessors were kept unaware of the treatment condition".

McDonagh 2005

MethodsRandomised controlled trial


Participants74 female childhood sexual abuse survivors with DSM-IV PTSD in the USA


Interventions7 x 2-hour and 7 x 1½-hour sessions of CBT (n = 29) versus 7 x 2-hour and 7 x 1½-hour sessions of PCT (n = 22) versus waitlist control (n = 23). (all interventions included in meta-analyses).


OutcomesCAPS, BDI, STAI, TSI, DES, STAXI


NotesExperienced therapists delivered therapy and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses using the LOCF method were performed. Reasons for drop-out were not fully reported. 12 participants dropped out of CBT, 2 from PCT and 3 from the waitlist.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasLow riskComment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "A separate group of female clinicians, who were blind to treatment condition and who had no other role in the study conducted the four CAPS interviews".

Monson 2006

MethodsRandomised controlled trial


Participants60 DSM-IV-TR PTSD. Combat veterans (54 men, 6 women) in the USA


Interventions12 sessions of cognitive processing therapy conducted twice weekly when possible (n = 30) vs waitlist (n = 30)


OutcomesCAPS, PCL, BDI, STAI


NotesExperienced therapists delivered therapy and treatment adherence was assessed


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote "Eligible participants were randomised to receive the treatment immediately or to wait for 10 weeks to receive the treatment (10 weeks was equivalent to the ideal 6 weeks of twice weekly sessions and the 1-month follow-up period for those in the CPT condition). The study biostatistician provided the participants’ condition assignment to the study coordinator."

Comment: The method of random sequence generation was not reported.

Allocation concealment (selection bias)Low riskQuote "Eligible participants were randomised to receive the treatment immediately or to wait for 10 weeks to receive the treatment (10 weeks was equivalent to the ideal 6 weeks of twice weekly sessions and the 1-month follow-up period for those in the CPT condition). The study biostatistician provided the participants’ condition assignment to the study coordinator."

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote "Primary analyses were performed according to the intention-to-treat principle; data from all participants were used regardless of their treatment completion."

Comment: 6 participants dropped out from the treatment group. 4 participants dropped out from the waitlist group.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasLow riskComment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote "The independent clinician assessors were blinded to condition assignment and participants were instructed to not disclose their condition assignment to them."

Mueser 2008

MethodsRandomised controlled trial


Participants108 DSM-IV PTSD individuals with severe mental illness receiving treatment at community health centres (46 men, 62 women) in the USA


Interventions12 - 16 sessions of TFCBT (n = 54) or TAU (n = 54)


OutcomesCAPS, PTSD knowledge test, BAI, BDI, BPRS, WAI, SF-12


NotesExperienced therapists delivered therapy and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of random sequence generation was not reported.

Allocation concealment (selection bias)Low riskQuote: "Randomization was conducted at a central location in the research centre by a computer-based randomizations program, with assignments not known in advance by either clinical or research staff."

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses were performed. 11 participants dropped out of the treatment group and 11 from TAU. 

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: There were no other obvious sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: “All assessments were conducted by master’s or Ph.D. level trained clinical interviewers who were blind to treatment assignment. Clients were instructed at the beginning of interviews to not talk about any treatments for trauma-related problems they may have received. Interviewers were requested to inform the project coordinator if the client broke the blind during an interview. Interviewers were not asked to guess clients’ treatment assignments, to avoid directly encouraging them to formulate hypotheses about how treatment may have affected clients’ symptoms, which could have influenced subsequent ratings. No specific instances of blind breaking were noted in the study.”

Neuner 2004

MethodsRandomised controlled trial


Participants43 Sudanese refugees in Uganda. All diagnosed with PTSD. (16 men, 27 women)


Interventions4 sessions of NET (n = 17) vs 4 sessions of supportive counselling (n = 14) vs one session of psychoeducation (n = 12) (NET and supportive counselling groups included in meta-analysis).


OutcomesPDS


NotesExperienced therapists delivered therapy. Treatment adherence was not monitored,


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Each participant was randomly assigned (using a dice) to one of three treatment groups: narrative exposure therapy, supportive counselling, or psychoeducation only."

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: One participant dropped out from NET and two from supportive counselling. ITT analyses were performed. Reasons for drop-out were not fully reported.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: The issue of researcher allegiance cannot be ruled out. Treatment adherence was not monitored.

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "The local and expert interviewers who carried out the posttests, as well as the follow-up tests, were blind for the individual participant’s treatmentcondition."

Neuner 2008

MethodsRandomised controlled trial


Participants277 Rwandan and Somalian refugees diagnosed with PTSD (142 women, 135 men)


InterventionsNET (n = 111) vs trauma counselling (n = 111) vs monitoring (n = 55) (NET and monitoring included in meta-analysis).


OutcomesPDS, DFMQ, SRQ-20, SF-12


NotesExperienced therapists delivered therapy. Treatment adherence was not monitored,


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "The participants were assigned to the groups in the following way: The list of participants was ordered randomly; the first 4 were consecutively assigned to the NET, TC, NET, and TC groups; and the fifth was assigned to the MG (monitoring) group. This procedure was repeated until all 277 participants were assigned."

Comment: The method of random sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "Aiming at an intention-to-treat analysis, we included in the outcome analysis all participants who were randomised. In anticipation of a high rate of missing data, we considered a last observation- carried-forward procedure as too conservative. Instead we chose to apply mixed-effects models that allow the inclusion of all available data without the arbitrary replacement or imputation of missing values."

Selective reporting (reporting bias)Low risk Comment: All specified outcomes were reported.

Other biasLow riskComment: A large number of participants could not be located for follow-up.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "The participants who received treatment were reassessed 3 and 6 months later by the same local research assistants who had carried out the interviews for the survey. They were blind with respect to the particular treatment condition."`

Neuner 2010

MethodsRandomised controlled trial


Participants32 asylum seekers with DSM-IV PTSD (22 men, 10 women) in Germany


InterventionsNET (n = 16) vs TAU (n = 16)


OutcomesPosttraumatic Stress Diagnostic Scale, Hopkins Symptom Checklist-25 depression Scale, Composite International Diagnostic Interview - C Pain Score


NotesExperienced therapists delivered therapy. Treatment adherence was not monitored


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "all the participants who were randomised were included in the outcome analysis."

Comment: 2 participants dropped out of the treatment group. Reasons for drop-out are not fully reported.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: The authors acknowledged having little information about the interventions prescribed as part of TAU. The issue of researcher allegiance cannot be ruled out. Treatment adherence was not monitored.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "we aimed at keeping interviewers blind to each participants condition."

Nijdam 2012

MethodsRandomised controlled trial


Participants140 adults with PTSD after a variety of different traumas (79 women, 61 men)


InterventionsBrief ecclectic psychotherapy (n = 70) or EMDR (n = 70)


OutcomesIES-R, SI-PTSD, HADS depression, HADS anxiety


NotesExperienced therapists delivered therapy. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of random sequence generation was not reported.

Allocation concealment (selection bias)Low riskA method of central allocation was employed, whereby a psychologist unassociated with the rest of the study used a computer programme.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses were performed. Reasons for treatment drop-out are fully reported, and unlikely to have caused bias. Missing data were imputed using appropriate methods. 28 individuals dropped out of EMDR and 22 from BEP.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasLow riskComment: The issue of researcher allegiance cannot be ruled out. Treatment adherence was not monitored.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "To ensure masking of assessors, one psychologist who had no other engagement in the study, had access to the computer program, kept a log file of all random assignments and assigned the patients to the therapists."

Paunovic 2011

MethodsRandomised controlled trial


Participants29 adult victims of crime with chronic PTSD (12 men, 17 women)


InterventionsExposure Inhibition Therapy (n = 14) vs waitlist (n = 15)


OutcomesCAPS, PCL, IES-R, BAI, BDI, CSE, PTSI


NotesExperienced therapists delivered therapy. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of random sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: The method of allocation concealement (if any) was not reported.

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: Reasons for drop-outs are not given. It is unclear how missing data were handled. There was one drop-out from each group.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskThere was only one author, who was seemingly responsible for all aspects of the study (recruitment, randomisation, assessment, therapy, analysis). The author had conceived the therapy that was being evaluated, based on a theory of PTSD they had previously formulated. The author acknowledged "this study must be replicated with a more rigorous design that fulfills all of the golden criteria for a randomized controlled study."

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
High riskQuote: "The assessor was both the therapist and the author of the current study."

Peniston 1991

MethodsRandomised controlled trial


Participants29 male Vietnam War combat veterans with DSM-III PTSD


Interventions48 x 30-minute sessions of EMG (n = 15) assisted desensitisation vs no treatment (n = 14)


OutcomesNightmare and flashback frequency


NotesTherapist credentials/experience is not reported. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: It is unclear if there were any missing data, or how this was handled.

Selective reporting (reporting bias)Low risk Comment: All specified outcomes were reported.

Other biasUnclear riskComment: The study is not well-reported. It is difficult to judge other sources of bias.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskComment: Blind assessors were used.

Power 2002

MethodsRandomised controlled trial


Participants105 outpatients with DSM-IV PTSD. Various traumas (gender of those starting the study unclear)


Interventions10 x 90-minute weekly sessions of EMDR (n = 39) vs exposure plus cognitive restructuring (n = 37) vs waitlist (n = 29) (all interventions included in meta-analyses).


OutcomesCAPS, HAM-A, MADRS


Notes Experienced therapists delivered therapy, and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Following completion of the entire initial assessment, for those patients who met entry criteria, the blind assessor then opened a sealed envelope that informed as to which group patients were to be allocated."

Allocation concealment (selection bias)Low riskQuote: "Following completion of the entire initial assessment, for those patients who met entry criteria, the blind assessor then opened a sealed envelope that informed as to which group patients were to be allocated."

Incomplete outcome data (attrition bias)
All outcomes
High riskQuote: "Comparison between the 33 drop-outs and the 72 completers regarding presentation at time of initial assessment produced no significant differences on any of the demographic characteristics or treatment outcome measures with the sole exception of a higher frequency score on the CAPS-C Avoidance subscale for the drop-outs t D 2.2, df D 103, p < 0.05. Subsequent analysis was conducted on the 72 completers."

Comment: There were 12 drop-outs from EMDR, 16 from EMDR plus cognitive restructuring and 5 from the waiting list. Reasons for drop-out were not fully reported.

Selective reporting (reporting bias)Low risk Comment: All specified outcomes were reported.

Other biasLow riskComment: no other sources of bias detected.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "However, assessment at entry, end-point and follow-up were conducted by ‘blind’ assessors."

Ready 2010

MethodsRandomised controlled trial


Participants11 Vietnam War veterans with DSM-IV PTSD with a CAPS score greater than 60 in the USA


Interventions10 sessions of Virtual Reality Exposure (n = 6) vs 10 sessions of person-centred therapy (n = 5)


OutcomesCAPS, BDI


NotesTherapist credentials/experience is not reported. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: One participant dropped out of each group. Reasons for drop-out are not reported. It is unclear how missing data were handled.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: PCT was developed as a control condition for the purposes of the study.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: “Participants were administered the measures or interviews at pretreatment, posttreatment, and six-month follow-up by a licensed clinical psychologist with 3 years of experience working with Vietnam veterans. She remained blind to treatment condition.”

Resick 2002

MethodsRandomised controlled trial


Participants171 female rape victims with DSM-IV PTSD


Interventions13 hours of cognitive processing therapy or exposure bi-weekly over 6 weeks (n = 124) versus minimal attention (n = 47).


OutcomesCAPS, PSS, BDI


NotesExperienced therapists delivered therapy, and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses using LOCF. 33 participants dropped out from TFCBT and 47 from the waitlist.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: The issue of researcher allegiance cannot be ruled out.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Independent raters who were not otherwise involved in the project conducted assessments of treatment adherence and therapist competence."

Rothbaum 1997

MethodsRandomised controlled trial


Participants21 female sexual assault victims with DSM-IIIR PTSD in the USA


Interventions3 weekly 90-minute sessions of EMDR (n = 11) vs wait list control (n = 9) (1 dropped out immediately after assessment).


OutcomesPSS, IES, BDI, STAI


NotesExperienced therapists delivered therapy, and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: 3 participants dropped out: 1 immediately after assessment, and 1 from each of the groups. ITT analyses were not performed.

Selective reporting (reporting bias)Low risk Comment: All specified outcomes were reported.

Other biasUnclear riskComment: Small sample size.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "independent assessor kept blind to the treatment condition".

Rothbaum 2005

MethodsRandomised controlled trial


Participants74 female rape victims in the USA


Interventions9 x 90-minute sessions of EMDR (25) vs 9 x 90-minute sessions of prolonged exposure (23) vs waiting list (24) (two dropped out prior to randomisation).


OutcomesCAPS, SLESQ, PSS-SR, IES-R, BDI, DES-II, STAI


NotesExperienced therapists delivered therapy, and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote "If the participant met criteria and gave consent, she was then randomised and scheduled accordingly".

Comment: It is unclear how the sequence was generated.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
High riskQuote: "Because only 2 of 14 participants who did not complete the study (1 in each of the active treatments) provide data other than baseline, intent-to-treat analyses provide no consequentially different results and are not included here."

Selective reporting (reporting bias)Low risk Comment: All specified outcomes were reported.

Other biasLow riskComment: No other sources of bias detected.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "All assessments were conducted by IAs who were kept blind to the treatment condition."

Scheck 1998

MethodsRandomised controlled trial


Participants60 16- to 25-year old female victims of various traumas. 77% DSM-IV PTSD in the USA


Interventions2 usually weekly sessions of EMDR (n = 30) vs active listening (n = 30)


OutcomesBDI, STAI, PENN, IES, TSCS


NotesExperienced therapists (volunteers) delivered therapy. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Envelopes filled with papers labelled either EMDR or AL were shuffled and numbered 1 through 100. During each interview, envelopes were opened consecutively".

Allocation concealment (selection bias)Low riskQuote: "Envelopes filled with papers labelled either EMDR or AL were shuffled and numbered 1 through 100. During each interview, envelopes were opened consecutively".

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: Reasons for drop-out were not fully reported (1 participant from AL, 1 from EMDR) . Only the data of completers are included in the analysis.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: It is unclear whether or not treatment adherence was assessed. Active listening was not intended as an effective intervention. The aim was to create a control that offered rapport, expectation of gain and sympathetic attention.

Blinding of participants and personnel (performance bias)
All outcomes
High riskQuote: Comment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskComment: Insufficient information.

Schnurr 2003

MethodsRandomised controlled trial


Participants360 male Vietnam War veterans with DSM-IV PTSD in the USA


InterventionsWeekly present-focused group CBT for 30 weeks (n = 180) vs weekly trauma-focused CBT group therapy for 30 weeks (n = 180)


OutcomesCAPS, GHQ, SF36


NotesExperienced therapists delivered therapy, and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskQuote: "The randomizations were performed using permuted blocks of 4 in 3 blocks of CAPS severity scores to ensure balance in treatment groups by CAPS score."

Comment: The method of random sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "Often, intention-to-treat analysis is performed by using an individual’s last measurement before treatment dropout as the last outcome or by carrying it forward. This method has been criticized for the bias it can introduce. Instead, we attempted to measure participants regardless of the number of treatment sessions they attended or their treatment dropout status. To our knowledge, no previous studies of PTSD treatment have taken this approach, which is standard in clinical trials in other fields of medicine. Therefore, we also performed secondary analyses to examine the effect of TFGT among participants who completed most of the scheduled sessions."

Comment: 62 dropped out from the TF group and 45 from the non-TF group.

Selective reporting (reporting bias)Unclear riskComment: All specified outcomes were reported.

Other biasLow riskComment: no other sources of bias detected.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote "Assessments were performed by a master’s- or doctoral level clinician who was unaware of treatment assignment."

Schnurr 2007

MethodsRandomised controlled trial


Participants284 female veterans and active duty personnel in the USA


Interventions10 weekly 90-minute sessions of prolonged exposure (n = 141) vs 10 weekly 90-minute sessions of present-centred therapy (n = 143)


OutcomesCAPS, SF36, SSAI, BDI, ASI, PTSD checklist


NotesExperienced therapists delivered therapy, and treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "Verified eligible participants were randomised within each site to prolonged exposure or present-centred therapy using permuted blocks with random block sizes of 4 or 6. All study data were stored at the study coordinating center."

Comment: The method of random sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "Primary analyses were performed on the intention-to-treat sample, using data from all randomised participants." Reasons for drop-out were fully reported (21 from PE and 17 from PCT).

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasLow riskComment: No other sources of bias detected.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Blinded assessors collected data before and after treatment and at 3- and 6-month follow-up."

Taylor 2003

MethodsRandomised controlled trial


Participants60 outpatients. Various traumas. DSM-IV PTSD.(45 women, 15 men) in the USA


Interventions8 90-minute sessions of exposure therapy (n = 22), EMDR (n = 19) or relaxation training (n = 19) (all interventions included in meta-analyses).


OutcomesCAPS, PDS, BDI


NotesExperienced therapists delivered therapy. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses. Drop-outs were from each group (exposure therapy (7), EMDR (4) or relaxation training (4).

Selective reporting (reporting bias)Unclear riskComment: Only measures of PTSD and depression are reported. It is unclear whether any other data were collected.

Other biasLow riskComment: no other sources of bias detected.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "All interviews were conducted by clinic staff, who were blind to the participants’ treatment assignment."

Vaughan 1994

MethodsRandomised controlled trial


Participants36 various traumas. 78% DSM-IIIR PTSD. (23 women, 13 men) in Australia


Interventions3 - 5 50-minute sessions of image habituation training (n = 13), EMDR (n = 12) or applied muscular relaxation (n = 11) (all interventions included in meta-analyses).


OutcomesPTSD structured interview, IES, STAI, BDI


NotesTherapist credentials/experience is not reported. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of random sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskQuote: "After assessment each subject was randomly assigned to a treatment group and also to a wait list or non-waitlist group. The procedure resulted in unequal numbers of subjects in the treatment groups -12 in EMD, 13 in IHT and 11 in AMR."

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: No drop-outs.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasLow riskComment: no other sources of bias detected.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "As a check of the independent rater’s blindness as to patients’ treatment categories, the rater was asked to guess the category post-treatment but was unable to do this better than by chance (x2 = 3.72, P = ns)."

Wells 2012

MethodsRandomised controlled trial


Participants20 individuals with DSM-IV PTSD (11 women, 9 men) in the UK


InterventionsMeta cognitive therapy (n = 10) vs delayed treatment (n = 10)


OutcomesPDS, IES, BDI, BAI, TSQ


NotesTherapist credentials/experience is not reported. Treatment adherence was not formally assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComment: Allocated by a coin toss.

Allocation concealment (selection bias)Low riskComment: Allocation was performed by an individual otherwise not involved with the study.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: ITT analyses were performed. One participant dropped out of the MCT group.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: Small sample size.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskComment: The assessor was blind.

Zang 2013

MethodsRandomised controlled trial


Participants22 (17 women, 5 men) adult survivors of the Sichuan earthquake with PTSD


InterventionsNET (n = 11) versus WL (n = 11)


OutcomesIES-R, GHQ-28, HADS, CIOQ, MSPSS, SCSQ


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of random sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: Specific methods of allocation concealment were not reported.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: No-one left the study early.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskComment: Very small sample size.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "The pre and post treatment assessments were carried out by a researcher not involved in treatment and blind to the treatment conditions."

Zlotnick 1997

MethodsRandomised controlled trial


Participants48 female sexual abuse survivors. All DSM-IIIR PTSD in the USA


Interventions15 2-hour sessions of group affective management (n = 24) vs waiting list control (n = 24)


OutcomesDTS, CR-PTSD, DES


NotesTherapist credentials/experience is not reported. It is unclear whether or not treatment adherence was assessed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: The method of sequence generation was not reported.

Allocation concealment (selection bias)Unclear riskComment: There is no mention of any measures taken to conceal allocation.

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: There were no reported reasons for drop-out (7 from treatment and 6 from the waitlist).Only the data of completers are included in the analysis.

Selective reporting (reporting bias)Low riskComment: All specified outcomes were reported.

Other biasHigh riskTherapist credentials/experience is not reported. It is unclear whether or not treatment adherence was assessed.

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: Participants were aware of their allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskSelf report measures only.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Abbasnejad 2007No formal diagnosis of PTSD.

Arntz 2007TFCBT vs TFCBT.

Barabasz 2013Unclear how many participants were suffering ASD as opposed to PTSD (length of time since trauma was not reported). Not a true RCT.

Boudewyns 1990Group treatment with exposure or conventional one-to-one counselling.

Chemtob 1997Treatment designed for anger vs PTSD with anger measures used as primary outcomes.

Classen 2001No formal diagnosis of PTSD.

Classen 2010No formal diagnosis of PTSD.

Cole 2007No formal diagnosis of PTSD.

Davis 2007Only 67.3% of participants met diagnostic criteria for PTSD before entry into study.

Difede 2007aOnly 67.7% of participants met diagnostic criteria for PTSD before entry into study.

DuHamel 2010Only 19% of participants met diagnostic criteria for PTSD before entry into study.

Dunn 2007Treatment for depression not PTSD.

Echeburua 1996Trauma < 3 months before entry into study.

Edmond 1999No formal diagnosis of PTSD.

Falsetti 2001No formal diagnosis of PTSD.

Falsetti 2005

Foa 2006Trauma < 3 months before entry into study.

Frommberger 2004Psychological therapy vs pharmacotherapy.

Gidron 1996Not psychological treatment.

Ginzberg 2009No diagnosis of PTSD.

Glynn 1999Not an individual or group therapy.

Hiari 2005Participants only required to meet re-experiencing and avoidance criteria of DSM-IV criteria for PTSD.

Jaberghaderi 2004Participants under 18 (study included in Gillies 2012).

Knaevelsrud 2007No formal diagnosis of PTSD.

Lange 2001No formal diagnosis of PTSD.

Lange 2003No formal diagnosis of PTSD.

Litz 2007No formal diagnosis of PTSD.

Maercker 2006Only 48% of participants met diagnostic criteria for PTSD. Remainder had a diagnosis of "sub-syndromal PTSD".

Mithoefer 2011TFCBT vs TFCBT.

Najavits 2006Mean age of participants 16 years [study included in Gillies 2012]

Paunovic 2001TFCBT vs TFCBT.

Price 2007No formal diagnosis of PTSD made.

Rabe 2008Only 48.5% of participants met diagnostic criteria for PTSD before entry into study.

Rothbaum 2006Pharmacotherapy versus pharmacotherapy plus psychological therapy.

Ryan 2005No formal diagnosis of PTSD.

Schaal 2009Age range 14 - 28.

Shapiro 1989aNo formal diagnosis of PTSD.

Sloan 2004No formal diagnosis of PTSD.

Sloan 2005No formal diagnosis of PTSD.

Spence 2011Information on duration was not collected. Unkown whether participants had acute/chronic PTSD.

Tarrier 1999Compared trauma focused cognitive therapy with exposure therapy therefore both treatments = TFCBT.

Tucker 2007Pharmacotherapy versus placebo.

Van Emmerik 2008Only 46.6% diagnosis of PTSD.

Watson 1997Considered 3 different types of relaxation training with no other comparison group.

Wilson 1995< 50% PTSD at entry to study.

Yeomans 2010No formal diagnosis of PTSD.

 
Characteristics of studies awaiting assessment [ordered by study ID]
Krupnick 2008

MethodsRandomised Controlled Trial

Participants37 female victims of domestic violence with DSM-III R PTSD

InterventionsGroup interpersonal psychotherapy (n = 32) versus WL (n = 16).

OutcomesCAPS, Interpersonal Sensitivity, Need for Social Approval, Lack of Sociability, and Interpersonal Ambivalence

Notes

 
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 symptoms - clinician32Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Clinician PTSD
281256Std. Mean Difference (IV, Random, 95% CI)-1.62 [-2.03, -1.21]

    1.2 Clinician PTSD severity women-only subgroup analysis)
9562Std. Mean Difference (IV, Random, 95% CI)-1.83 [-2.31, -1.36]

    1.3 Clinician PTSD excluding studies of Vietnam War veterans
271232Std. Mean Difference (IV, Random, 95% CI)-1.67 [-2.09, -1.25]

    1.4 Self report
16666Std. Mean Difference (IV, Random, 95% CI)-1.57 [-2.01, -1.14]

 2 Severity of PTSD symptoms at 1 - 4 month follow-up4Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 Clinician
4336Std. Mean Difference (IV, Random, 95% CI)-1.18 [-2.20, -0.17]

 3 Severity of PTSD symptoms at 5 - 8 month follow-up.3192Std. Mean Difference (IV, Fixed, 95% CI)-0.47 [-0.77, -0.18]

 4 Severity of PTSD symptoms 9 - 12 month follow-up1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 5 Leaving the study early for any reason331756Risk Ratio (M-H, Fixed, 95% CI)1.64 [1.30, 2.06]

 6 Severity of PTSD symptoms - self report: 1 - 4 month follow-up2181Std. Mean Difference (IV, Random, 95% CI)-3.03 [-6.51, 0.45]

 7 Severity of PTSD symptoms - self report: 5 - 8 months)2208Std. Mean Difference (IV, Fixed, 95% CI)-0.61 [-0.90, -0.32]

 8 Severity of PTSD symptoms - self report: 9 - 12 month follow up1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 9 Depression281213Std. Mean Difference (IV, Random, 95% CI)-1.28 [-1.62, -0.94]

 10 Depression 1 - 4 month follow-up7413Std. Mean Difference (IV, Random, 95% CI)-0.75 [-1.33, -0.18]

 11 Depression 5 - 8 month follow-up2150Std. Mean Difference (IV, Fixed, 95% CI)-0.50 [-0.82, -0.17]

 12 Depression 9 - 12 month follow-up1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 13 Anxiety17644Std. Mean Difference (IV, Random, 95% CI)-0.81 [-1.03, -0.59]

 14 Anxiety 1 - 4 month follow-up3189Std. Mean Difference (IV, Fixed, 95% CI)-0.32 [-0.60, -0.03]

 15 Anxiety 9 - 12 month follow-up1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 16 Exploration of publication bias28Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    16.1 Clinician
281256Std. Mean Difference (IV, Random, 95% CI)-1.62 [-2.03, -1.21]

 17 Sensitivity analysis - clinician-rated PTSD symptoms - studies at low risk of bias only1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 18 PTSD diagnosis after treatment19910Risk Ratio (M-H, Random, 95% CI)0.51 [0.41, 0.64]

 
Comparison 2. Trauma-focused CBT/Exposure therapy vs non-TFCBT

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Severity of PTSD Symptoms - clinician7267Std. Mean Difference (IV, Random, 95% CI)-0.27 [-0.63, 0.10]

 2 Severity of PTSD symptoms - clinician - follow-up (1 - 4 months)5127Std. Mean Difference (IV, Random, 95% CI)-0.51 [-1.00, -0.01]

 3 Severity of PTSD symptoms - clinician - follow-up (5 - 8 months)248Std. Mean Difference (IV, Random, 95% CI)1.00 [-2.17, 0.17]

 4 Severity of PTSD symptoms - clinician - follow-up (9 - 12 months)248Mean Difference (IV, Fixed, 95% CI)-12.93 [-18.72, -7.14]

 5 Leaving the study early for any reason7312Risk Ratio (M-H, Fixed, 95% CI)1.19 [0.71, 2.00]

 6 Severity of PTSD symptoms - self report3127Std. Mean Difference (IV, Fixed, 95% CI)-0.37 [-0.74, 0.01]

 7 Severity of PTSD symptoms - self report - follow-up (1-4 months)254Std. Mean Difference (IV, Fixed, 95% CI)-0.44 [-0.99, 0.10]

 8 Depression6189Std. Mean Difference (IV, Fixed, 95% CI)-0.27 [-0.56, 0.03]

 9 Depression - follow-up (1 - 4 months)5147Std. Mean Difference (IV, Fixed, 95% CI)-0.28 [-0.62, 0.06]

 10 Depression - follow-up (5 - 8 months)248Std. Mean Difference (IV, Fixed, 95% CI)-0.71 [-1.30, -0.12]

 11 Depression - follow-up (9 - 12 months)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 12 Anxiety4127Std. Mean Difference (IV, Fixed, 95% CI)-0.12 [-0.49, 0.26]

 13 Anxiety - follow-up (1 - 4 months)4117Std. Mean Difference (IV, Random, 95% CI)-0.24 [-0.79, 0.30]

 14 Anxiety - follow-up (5 - 8 months)1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 15 Anxiety - follow-up (9 - 12 months)1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 16 PTSD diagnosis after treatment6284Risk Ratio (M-H, Random, 95% CI)0.83 [0.60, 1.17]

 
Comparison 3. Trauma-focused CBT/Exposure Therapy vs other therapies

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Severity of PTSD symptoms - clinician10625Std. Mean Difference (IV, Random, 95% CI)-0.48 [-0.83, -0.14]

 2 Severity of PTSD symptoms - clinician - 1 - 4 month follow-up8548Std. Mean Difference (IV, Random, 95% CI)-0.34 [-0.64, -0.04]

 3 Severity of PTSD symptoms - clinician - 5 - 8 month follow-up4434Std. Mean Difference (IV, Random, 95% CI)-0.58 [-1.20, 0.04]

 4 Severity of PTSD symptoms - clinician - 9 - 12 month follow-up290Std. Mean Difference (IV, Random, 95% CI)-0.76 [-1.35, -0.17]

 5 Leaving the study early for any reason11762Risk Ratio (M-H, Fixed, 95% CI)1.39 [1.01, 1.92]

 6 Severity of PTSD symptoms - self report6574Std. Mean Difference (IV, Random, 95% CI)-0.60 [-1.15, -0.06]

 7 Severity of PTSD symptoms - self report - follow-up (1 - 4 months)5526Std. Mean Difference (IV, Fixed, 95% CI)-0.29 [-0.47, -0.12]

 8 Severity of PTSD symptoms - self-report - follow-up (5 - 8 months)3338Std. Mean Difference (IV, Random, 95% CI)-0.90 [-2.05, 0.25]

 9 Severity of PTSD symptoms - self-report - follow-up (9 - 12 months)290Mean Difference (IV, Fixed, 95% CI)-2.66 [-5.71, 0.38]

 10 Depression - self report9570Std. Mean Difference (IV, Random, 95% CI)-0.37 [-0.63, -0.11]

 11 Depression - self-report - follow-up (1-4 months)7510Std. Mean Difference (IV, Random, 95% CI)-0.29 [-0.62, 0.03]

 12 Depression - follow-up (5-8 months)5443Std. Mean Difference (IV, Random, 95% CI)-0.43 [-0.87, 0.01]

 13 Depression 9-12 month follow up1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 14 Anxiety - self report7539Std. Mean Difference (IV, Random, 95% CI)-0.45 [-0.77, -0.12]

 15 Anxiety - self-report - follow-up (1 - 4 months)5454Std. Mean Difference (IV, Random, 95% CI)-0.33 [-0.68, 0.02]

 16 Anxiety - follow-up (5 - 8 months)2329Std. Mean Difference (IV, Random, 95% CI)-0.56 [-1.69, 0.58]

 17 PTSD diagnosis after treatment7358Risk Ratio (M-H, Random, 95% CI)0.75 [0.59, 0.96]

 18 Severity of PTSD symptoms - clinician - 13-24 month follow-up1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 19 Sensitivity analysis - PTSD symptoms - studies at low risk of bias only1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 20 Sensitivity analysis - drop-out - studies at low risk of bias only1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 21 Subgroup analysis: severity of PTSD symptoms - women-only studies3129Std. Mean Difference (IV, Random, 95% CI)0.03 [-0.42, 0.47]

 22 Subgroup analysis: severity of PTSD symptoms - clinician - excluding Vietnam veterans9599Std. Mean Difference (IV, Random, 95% CI)-0.46 [-0.80, -0.11]

 
Comparison 4. EMDR vs waitlist/usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Severity of PTSD symptoms - Clinician6183Std. Mean Difference (IV, Random, 95% CI)-1.17 [-2.04, -0.30]

 2 Leaving study early due to any reason7227Risk Ratio (M-H, Fixed, 95% CI)1.05 [0.62, 1.79]

 3 Severity of PTSD symptoms - self report6159Std. Mean Difference (IV, Random, 95% CI)-0.80 [-1.68, 0.07]

 4 Depression7226Std. Mean Difference (IV, Random, 95% CI)-1.15 [-1.52, -0.78]

 5 Anxiety6160Std. Mean Difference (IV, Fixed, 95% CI)-1.02 [-1.36, -0.69]

 6 PTSD diagnosis after treatment6209Risk Ratio (M-H, Fixed, 95% CI)0.51 [0.42, 0.62]

 
Comparison 5. EMDR vs Trauma-focused CBT

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Severity of PTSD symptoms - clinician7327Std. Mean Difference (IV, Random, 95% CI)-0.03 [-0.43, 0.38]

 2 Severity of PTSD symptoms - clinician - follow-up (1 - 4 months)376Std. Mean Difference (IV, Random, 95% CI)-0.19 [-0.97, 0.58]

 3 Leaving study early for any reason8408Risk Ratio (M-H, Fixed, 95% CI)1.00 [0.74, 1.35]

 4 Severity of PTSD symptoms - self report7306Std. Mean Difference (IV, Random, 95% CI)-0.30 [-0.60, 0.01]

 5 Severity of PTSD symptoms - self-report - follow-up (1 - 4 months)5111Std. Mean Difference (IV, Random, 95% CI)-0.04 [-0.61, 0.52]

 6 Depression8346Std. Mean Difference (IV, Random, 95% CI)-0.31 [-0.75, 0.13]

 7 Depression - follow-up (1 - 4 months)5111Std. Mean Difference (IV, Random, 95% CI)-0.13 [-0.64, 0.38]

 8 Anxiety4236Std. Mean Difference (IV, Fixed, 95% CI)-0.28 [-0.53, -0.02]

 9 Anxiety - follow-up (1 - 4 months)248Std. Mean Difference (IV, Fixed, 95% CI)0.24 [-0.33, 0.81]

 10 PTSD diagnosis after treatment8350Risk Ratio (M-H, Fixed, 95% CI)0.95 [0.74, 1.22]

 
Comparison 6. EMDR vs non-TFCBT

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 (1-4 months)371Std. Mean Difference (IV, Random, 95% CI)-0.74 [-1.64, 0.15]

 3 Leaving the study early for any reason384Risk Ratio (M-H, Fixed, 95% CI)1.03 [0.37, 2.88]

 4 Severity of PTSD symptoms - self report375Std. Mean Difference (IV, Fixed, 95% CI)-0.40 [-0.86, 0.06]

 5 Severity of PTSD symptoms - self-report - follow-up (1 - 4 months)375Std. Mean Difference (IV, Fixed, 95% CI)-0.52 [-0.98, -0.05]

 6 Depression375Std. Mean Difference (IV, Fixed, 95% CI)-0.67 [-1.14, -0.20]

 7 Depression - follow-up (1 - 4 months)375Std. Mean Difference (IV, Random, 95% CI)-0.25 [-0.86, 0.36]

 8 Anxiety245Std. Mean Difference (IV, Fixed, 95% CI)-0.75 [-1.36, -0.13]

 9 Anxiety - follow-up (1 - 4 months)245Std. Mean Difference (IV, Random, 95% CI)-0.42 [-2.21, 1.37]

 10 PTSD diagnosis after treatment384Risk Ratio (M-H, Random, 95% CI)0.71 [0.41, 1.22]

 
Comparison 7. EMDR vs other therapies

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Leaving study early for any reason2127Risk Ratio (M-H, Fixed, 95% CI)1.48 [0.26, 8.54]

 2 Severity of PTSD symptoms - self report2124Std. Mean Difference (IV, Fixed, 95% CI)-0.84 [-1.21, -0.47]

 3 Depression2127Std. Mean Difference (IV, Fixed, 95% CI)-0.67 [-1.03, -0.32]

 4 Anxiety2126Std. Mean Difference (IV, Fixed, 95% CI)-0.72 [-1.08, -0.36]

 5 PTSD diagnosis after treatment1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 8. Non-TFCBT vs waitlist/usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Severity of PTSD symptoms - Clinician4106Std. Mean Difference (IV, Random, 95% CI)-1.22 [-1.76, -0.69]

 2 Leaving the study early for any reason5141Risk Ratio (M-H, Fixed, 95% CI)1.96 [0.70, 5.48]

 3 Severity of PTSD symptoms - Self-report244Std. Mean Difference (IV, Random, 95% CI)-0.86 [-3.27, 1.55]

 4 Depression5129Std. Mean Difference (IV, Random, 95% CI)-0.93 [-1.43, -0.42]

 5 Anxiety4102Std. Mean Difference (IV, Fixed, 95% CI)-0.83 [-1.24, -0.42]

 6 PTSD diagnosis after treatment4121Risk Ratio (M-H, Random, 95% CI)0.65 [0.50, 0.86]

 
Comparison 9. Non-TFCBT vs other therapies

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Severity of PTSD symptoms - Clincian1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 2 Severity of PTSD symptoms - clinician - follow-up (3 months)1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Leaving the study early for any reason1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Depression - self report1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 5 Depression - self report - follow-up (3 months)1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 6 Anxiety - self report1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 7 Anxiety - self report - follow-up (3 months)1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 8 PTSD diagnosis after treatment1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 10. Group TFCBT vs waitlist/usual care/minimal contact

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Clinician-rated3185Std. Mean Difference (IV, Random, 95% CI)-1.28 [-2.25, -0.31]

 2 Severity of PTSD 5 - 8 month follow-up1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Leaving the study early for any reason7573Risk Ratio (M-H, Fixed, 95% CI)1.21 [0.94, 1.55]

 4 Severity of PTSD symptoms - self report6274Std. Mean Difference (IV, Random, 95% CI)-1.20 [-1.70, -0.69]

 5 Severity of PTSD - self report - 1 - 4 months273Std. Mean Difference (IV, Random, 95% CI)-1.14 [-1.78, -0.50]

 6 Depression3137Std. Mean Difference (IV, Random, 95% CI)-1.15 [-1.98, -0.32]

 7 Depression 1 - 4 month follow-up1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 8 Anxiety3106Std. Mean Difference (IV, Fixed, 95% CI)-0.66 [-1.06, -0.27]

 9 Anxiety 1 - 4 month follow-up273Mean Difference (IV, Fixed, 95% CI)-0.43 [-0.72, -0.14]

 10 PTSD diagnosis after treatment1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 11. Group CBT (trauma-focused) vs Group CBT (non-trauma-focused)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Severity of PTSD symptoms1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 2 Leaving the study early for any reason1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 PTSD diagnosis after treatment1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 12. Other therapies vs waitlist/usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Severity of PTSD symptoms - clinician3112Std. Mean Difference (IV, Fixed, 95% CI)-0.58 [-0.96, -0.20]

 2 Leaving the study early due to any reason4211Risk Ratio (M-H, Fixed, 95% CI)2.45 [0.99, 6.10]

 3 Severity of PTSD symptoms - self report2132Std. Mean Difference (IV, Fixed, 95% CI)-0.61 [-0.98, -0.24]

 4 Depression3112Std. Mean Difference (IV, Fixed, 95% CI)-0.45 [-0.83, -0.07]

 5 Anxiety - Self report4193Std. Mean Difference (IV, Fixed, 95% CI)-0.52 [-0.82, -0.22]

 6 PTSD diagnosis after treatment4210Risk Ratio (M-H, Random, 95% CI)0.80 [0.61, 1.05]

 
Comparison 13. Group non-TFCBT vs waitlist/usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Leaving the study early for any reason1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Severity of PTSD symptoms - self report1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Severity of PTSD symptoms - self report 1 - 4 months1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 4 Depression1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 5 Depression - 1 - 4 months1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

 
Summary of findings for the main comparison. Trauma-focused CBT/Exposure therapy compared with Waitlist/Usual Care for chronic post-traumatic stress disorder (PTSD) in adults

Trauma-focused CBT/Exposure therapy versus Waitlist/Usual Care

Patient or population: Adults with PTSD for at least 3 months
Settings: Primary care, community, outpatient
Intervention: Trauma-focused CBT/Exposure Therapy

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

ControlTrauma Focused CBT/ Exposure Therapy

Severity of PTSD symptoms - Clinician-ratedThe mean severity of PTSD symptoms - clinician-rated in the intervention groups was1.62 standard deviations lower
(2.03 to 1.21 lower)
1256
(28 studies)
⊕⊝⊝⊝
very low1,2,3

Leaving the study early for any reasonStudy populationRR 1.64
(1.30 to 2.06)
1756
(33 studies)
⊕⊝⊝⊝
very low1,2,3

130 per 1000189 per 1000
(150 to 240)

Moderate

85 per 1000124 per 1000
(99 to 157)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Some studies were judged to pose a high risk of bias
2Unexplained heterogeneity
3Small sample sizes
 
Summary of findings 2. Trauma-focused CBT/Exposure therapy compared with non-TFCBT for chronic post-traumatic stress disorder (PTSD) in adults

Trauma-focused CBT/Exposure therapy compared with non-TFCBT for chronic post-traumatic stress disorder (PTSD) in adults

Patient or population: Adults with PTSD for at least 3 months
Settings: Primary care, community, outpatient
Intervention: Trauma-focused CBT/Exposure therapy
Comparison: non-Trauma-focused CBT

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Non-TFCBTTrauma Focused CBT/ Exposure Therapy

Severity of PTSD Symptoms - Clinician-ratedThe mean severity of PTSD symptoms - clinician-rated in the intervention groups was
0.27 standard deviations lower
(0.63 lower to 0.10 higher)
267
(7 studies)
⊕⊝⊝⊝
very low1,2

Leaving the study early for any reasonStudy populationRR 1.19
(0.71 to 2.00)
312
(7 studies)
⊕⊝⊝⊝
very low1,2,3

154 per 1000183 per 1000
(109 to 308)

Moderate

154 per 1000183 per 1000
(109 to 308)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Some studies were judged to pose a high risk of bias
2Unexplained heterogeneity
3Small sample sizes
 
Summary of findings 3. Trauma-focused CBT/Exposure therapy compared with other therapies for chronic post-traumatic stress disorder (PTSD) in adults

Trauma-focused CBT/Exposure therapy compared with other therapies for chronic post-traumatic stress disorder (PTSD) in adults

Patient or population: Adults with PTSD for at least 3 months
Settings: Primary care, community, outpatient
Intervention: Trauma-focused CBT/Exposure therapy
Comparison: other therapies

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Other TherapiesTrauma Focused CBT/Exposure Therapy

Severity of PTSD symptoms - Clinician-ratedThe mean severity of PTSD symptoms - clinician in the intervention groups was-0.48 standard deviations lower
(-0.83 to -0.43 lower)
612
(10 studies)
⊕⊝⊝⊝
very low1,2,3

Leaving the study early for any reasonStudy populationRR 1.39
(1.01 to 1.92)
762
(11 studies)
⊕⊝⊝⊝
very low1,2,3

142 per 1000198 per 1000
(144 to 274)

Moderate

138 per 1000192 per 1000
(139 to 265)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Some studies were judged to pose a high risk of bias
2Unexplained heterogeneity
3Small sample sizes
 
Summary of findings 4. EMDR compared with Waitlist/Usual Care for chronic post-traumatic stress disorder (PTSD) in adults

EMDR compared with Waitlist/Usual Care for chronic post-traumatic stress disorder (PTSD) in adults

Patient or population: Adults with PTSD for at least 3 months
Settings: Primary care, community, outpatient
Intervention: Eye movement desensitization and reprocessing (EMDR)
Comparison: Waitlist/Usual Care

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Waitlist/Usual CareEMDR

Severity of PTSD symptoms - Clinician-ratedThe mean severity of PTSD symptoms - clinician in the intervention groups was1.17 standard deviations lower
(2.04 to 0.30 lower)
183
(6 studies)
⊕⊝⊝⊝
very low1,2,3

Leaving study early for any reasonStudy populationRR 1.05
(0.62 to 1.79)
227
(7 studies)
⊕⊝⊝⊝
very low1,3

178 per 1000188 per 1000
(104 to 313)

Moderate

172 per 1000182 per 1000
(101 to 305)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Some studies were judged to pose a high risk of bias
2Unexplained heterogeneity
3Small sample sizes
 
Summary of findings 5. EMDR compared with Trauma-focused CBT for chronic post-traumatic stress disorder (PTSD) in adults

EMDR compared with Trauma-focused CBT for chronic post-traumatic stress disorder (PTSD) in adults

Patient or population: Adults with PTSD for at least 3 months
Settings: Primary care, community, outpatient
Intervention: Eye movement desensitization and reprocessing (EMDR)
Comparison: Trauma-focused CBT

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Trauma Focused CBTEMDR

Severity of PTSD symptoms - Clinician-ratedThe mean severity of PTSD symptoms - clinician in the intervention groups was0.03 standard deviations lower
(0.43 lower to 0.38 higher)
327
(7 studies)
⊕⊝⊝⊝
very low1,2,3

Leaving study early for any reasonStudy populationRR 1.00
(0.74 to 1.35)
400
(8 studies)
⊕⊝⊝⊝
very low1,2,3

279 per 1000268 per 1000
(191 to 367)

Moderate

257 per 1000247 per 1000
(174 to 342)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Some studies were judged as posing a high risk of bias
2Unexplained heterogeneity
3Small sample sizes
 
Summary of findings 6. EMDR compared with non-TFCBT for chronic post-traumatic stress disorder (PTSD) in adults

EMDR compared with non-TFCBT for chronic post-traumatic stress disorder (PTSD) in adults

Patient or population: Adults with PTSD for at least 3 months
Settings: Primary care, community, outpatient
Intervention: Eye movement desensitization and reprocessing (EMDR)
Comparison: non-trauma-focused CBT

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Non-TFCBTEMDR

Severity of PTSD symptoms - Clinician-ratedThe mean severity of PTSD symptoms - clinician in the intervention groups was0.35 standard deviations lower
(0.90 lower to 0.19 higher)
53
(2 studies)
⊕⊝⊝⊝
very low1,2

Leaving the study early for any reasonStudy populationRR 1.03
(0.37 to 2.88)
84
(3 studies)
⊕⊝⊝⊝
very low1,2

140 per 1000144 per 1000
(46 to 367)

Moderate

91 per 100094 per 1000
(29 to 264)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Studies reported insufficient information to judge risk of bias
2Small sample sizes. Only two studies.
 
Summary of findings 7. EMDR compared with other therapies for chronic post-traumatic stress disorder (PTSD) in adults

EMDR compared with other therapies for chronic post-traumatic stress disorder (PTSD) in adults

Patient or population: Adults with PTSD for at least 3 months
Settings: Primary care, community, outpatient
Intervention: Eye movement desensitization and reprocessing (EMDR)
Comparison: other therapies

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Other TherapiesEMDR

Leaving study early for any reasonStudy populationRR 1.48
(0.26 to 8.54)
127
(2 studies)
⊕⊝⊝⊝
very low1,2

32 per 100047 per 1000
(8 to 234)

Moderate

32 per 100048 per 1000
(8 to 236)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1One study was judged to pose a high risk of bias. The other study reported insufficient information for a judgement to be made
2Only two studies. Small sample sizes
 
Summary of findings 8. Non-TFCBT compared with Waitlist/Usual Care for chronic post-traumatic stress disorder (PTSD) in adults

Non-TFCBT compared with Waitlist/Usual Care for chronic post-traumatic stress disorder (PTSD) in adults

Patient or population: Adults with PTSD for at least 3 months
Settings: Primary care, community, outpatient
Intervention: non-trauma-focused CBT
Comparison: Waitlist/Usual Care

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Waitlist/Usual CareNon-TFCBT Therapy

Severity of PTSD symptoms - Clinician-ratedThe mean severity of PTSD symptoms - clinician in the intervention groups was
1.22 standard deviations lower
(1.76 to 0.69 lower)
106
(4 studies)
⊕⊝⊝⊝
very low1,2,3

Leaving the study early due to any reasonStudy populationRR 1.96
(0.70 to 5.48)
141
(5 studies)
⊕⊝⊝⊝
very low1,2,3

78 per 1000153 per 1000
(55 to 428)

Moderate

83 per 1000163 per 1000
(58 to 455)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Insufficient data to judge risk of bias
2Unexplained heterogeneity
3Small sample sizes
 
Summary of findings 9. Non-TFCBT compared with other therapies for chronic post-traumatic stress disorder (PTSD) in adults

Non-TFCBT compared with other therapies for chronic post-traumatic stress disorder (PTSD)

Patient or population: Adults with PTSD for at least 3 months
Settings: Primary care, community, outpatient
Intervention: non-trauma-focused CBT
Comparison: other therapies

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Non-TFCBT

Severity of PTSD symptoms - Clincian-ratedSee commentSee commentNot estimable25
(1 study)
⊕⊝⊝⊝
very low1,2,3

Leaving the study early for any reasonSee commentSee commentNot estimable31
(1 study)
⊕⊝⊝⊝
very low1,2,3

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Some studies were judged to pose a high risk of bias
2Unexplained heterogeneity
3Small sample sizes
 
Summary of findings 10. Group TFCBT compared with Waitlist/Usual Care for chronic post-traumatic stress disorder (PTSD) in adults

Group TFCBT compared with Waitlist/Usual Care for chronic post-traumatic stress disorder (PTSD)

Patient or population: Adults with PTSD for at least 3 months
Settings: Primary care, community, outpatient
Intervention: Group TFCBT
Comparison: Waitlist/Usual Care/Minimal Contact

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Group TFCBT

Severity of PTSD symptoms - Clinician-rated The mean severity of PTSD symptoms - clinician in the intervention groups was
1.28 standard deviations lower
(2.25 to 0.31 lower)
185
(3 studies)
⊕⊝⊝⊝
very low1,2,3

Leaving the study early for any reasonStudy populationRR 1.21
(0.94 to 1.55)
573
(7 studies)
⊕⊝⊝⊝
very low1,2,3

262 per 1000317 per 1000
(246 to 406)

Moderate

200 per 1000242 per 1000
(188 to 310)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Insufficient information to judge risk of bias
2Unexplained heterogeneity
3Small sample sizes
 
Summary of findings 11. Group TFCBT compared with Group non-TFCBT for chronic post-traumatic stress disorder (PTSD) in adults

Group CBT (trauma focused) compared with Group CBT (non-trauma focused) for chronic post-traumatic stress disorder (PTSD) in adults

Patient or population: Adults with PTSD for at least 3 months
Settings: Primary care, community, outpatient
Intervention: Group TFCBT
Comparison: Group non-TFCBT

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Group CBT (non-trauma focused)Group CBT (trauma focused)

Severity of PTSD symptoms - Clinician-ratedSee commentSee commentNot estimable325
(1 study)
⊕⊝⊝⊝
very low1,2

Leaving the study early for any reasonSee commentSee commentNot estimable360
(1 study)
⊕⊝⊝⊝
very low1,2

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Insufficient information to judge risk of bias
2One study with a small sample size
 
Summary of findings 12. Other therapies compared with Waitlist/Usual Care for chronic post-traumatic stress disorder (PTSD) in adults

Other therapies compared with Waitlist/Usual Care for chronic post-traumatic stress disorder (PTSD) in adults

Patient or population: Adults with PTSD for at least 3 months
Settings: Primary care, community, outpatient
Intervention: Other therapies
Comparison: Waitlist/Usual Care

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Waitlist/Usual CareOther therapies

Severity of PTSD symptoms - ClinicianThe mean severity of PTSD symptoms - clinician in the intervention groups was
0.58 standard deviations lower
(0.96 to 0.20 lower)
112
(3 studies)
⊕⊝⊝⊝
very low1

Leaving the study early due to any reasonStudy populationRR 2.45
(0.99 to 6.10)
211
(4 studies)
⊕⊝⊝⊝
very low1,2

74 per 1000181 per 1000
(73 to 452)

Moderate

72 per 1000176 per 1000
(71 to 439)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Small sample sizes
2Studies were judged to pose a low/unclear risk of bias
 
Summary of findings 13. Group non-TFCBT compared with Waitlist/Usual Care for chronic post-traumatic stress disorder (PTSD) in adults

Group non-TFCBT compared to Waitlist/Usual Care for chronic post-traumatic stress disorder (PTSD) in adults

Patient or population: Adults with PTSD for at least 3 months
Settings: Primary care, community, outpatient
Intervention: Group non-TFCBT
Comparison: Waitlist/Usual Care

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Waitlist/Usual CareGroup nonTFCBT

Leaving the study early for any reasonSee commentSee commentNot estimable47
(1 study)
⊕⊝⊝⊝
very low1,2

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Only one study. Risk of bias high/unclear in several domains.
2Only one study