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Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD)

  1. Sarah E Hetrick1,*,
  2. Rosemary Purcell2,
  3. Belinda Garner2,
  4. Ruth Parslow3

Editorial Group: Cochrane Depression, Anxiety and Neurosis Group

Published Online: 7 JUL 2010

Assessed as up-to-date: 8 JUN 2010

DOI: 10.1002/14651858.CD007316.pub2

Database Title

Additional Information

How to Cite

Hetrick SE, Purcell R, Garner B, Parslow R. Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD007316. DOI: 10.1002/14651858.CD007316.pub2.

Author Information

  1. 1

    University of Melbourne, Centre of Excellence in Youth Mental Health, Orygen Youth Health Research Centre, Centre for Youth Mental Health, Melbourne, Victoria, Australia

  2. 2

    Orygen Youth Health Research Centre, Department of Psychiatry, Melbourne, Victoria, Australia

  3. 3

    University of Melbourne, Australian Centre for Posttraumatic Mental Health, East Melbourne, Victoria, Australia

*Sarah E Hetrick, Centre of Excellence in Youth Mental Health, Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, Locked Bag 10, 35 Poplar Road, Parkville, Melbourne, Victoria, 3054, Australia. shetrick@unimelb.edu.au.

Publication History

  1. Publication Status: New
  2. Published Online: 7 JUL 2010

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Resumen

Background

PTSD is an anxiety disorder related to exposure to a severe psychological trauma. Symptoms include re-experiencing the event, avoidance and arousal as well as distress and impairment resulting from these symptoms.

Guidelines suggest a combination of both psychological therapy and pharmacotherapy may enhance treatment response, especially in those with more severe PTSD or in those who have not responded to either intervention alone.

Objectives

To assess whether the combination of psychological therapy and pharmacotherapy provides a more efficacious treatment for PTSD than either of these interventions delivered separately.

Search methods

Searches were conducted on the trial registers kept by the CCDAN group (CCDANCTR-Studies and CCDANCTR-References) to June 2010. The reference sections of included studies and several conference abstracts were also scanned.

Selection criteria

Patients of any age or gender, with chronic or recent onset PTSD arising from any type of event relevant to the diagnostic criteria were included. A combination of any psychological therapy and pharmacotherapy was included and compared to wait list, placebo, standard treatment or either intervention alone. The primary outcome was change in total PTSD symptom severity. Other outcomes included changes in functioning, depression and anxiety symptoms, suicide attempts, substance use, withdrawal and cost.

Data collection and analysis

Two or three review authors independently selected trials, assessed their 'risk of bias' and extracted trial and outcome data. We used a fixed-effect model for meta-analysis. The relative risk was used to summarise dichotomous outcomes and the mean difference and standardised mean difference were used to summarise continuous measures.

Main results

Four trials were eligible for inclusion, one of these trials (n =24) was on children and adolescents. All used an SSRI and prolonged exposure or a cognitive behavioural intervention. Two trials compared combination treatment with pharmacological treatment and two compared combination treatment with psychological treatment. Only two trials reported a total PTSD symptom score and these data could not be combined. There was no strong evidence to show if there were differences between the group receiving combined interventions compared to the group receiving psychological therapy (mean difference 2.44, 95% CI -2.87, 7.35 one study, n=65) or pharmacotherapy (mean difference -4.70, 95% CI -10.84 to 1.44; one study, n = 25). Trialists reported no significant differences between combination and single intervention groups in the other two studies. There were very little data reported for other outcomes, and in no case were significant differences reported.

Authors' conclusions

There is not enough evidence available to support or refute the effectiveness of combined psychological therapy and pharmacotherapy compared to either of these interventions alone. Further large randomised controlled trials are urgently required.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Resumen

Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD)

PTSD is a potentially debilitating anxiety disorder triggered by exposure to a traumatic experience such as an interpersonal event like physical or sexual assault, exposure to disaster or accidents, combat or witnessing a traumatic event. There are three main clusters of symptoms: firstly, those related to re-experiencing the event; secondly, those related to avoidance and arousal; and thirdly, the distress and impairment caused by the first two symptom clusters.

Both psychological therapy and pharmacotherapy have been used to treat PTSD and guidelines suggest that a combination of both may mean people recover from PTSD more effectively. Four trials including 124 participants were included in this review. One of these trials (n =24) was on children and adolescents. The trials all used SSRIs and prolonged exposure or a cognitive behavioural intervention. Only two trials reported on total PTSD symptoms but the data could not be combined.

In this review, there are too few studies to be able to draw conclusions about whether a combination of psychological therapy and pharmacotherapy result in better outcomes for patients than either of these treatments alone.

 

Resumen

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Resumen

Antecedentes

Tratamiento farmacológico y terapia psicológica combinados para el trastorno de estrés postraumático (TEPT)

El TEPT es un trastorno de ansiedad relacionado con la exposición a un trauma psicológico severo. Los síntomas incluyen reviviscencia del evento, evasión y excitación así como sufrimiento y deterioro como resultado de estos síntomas.

Las guías indican que la combinación de terapia psicológica y tratamiento farmacológico puede mejorar la respuesta al tratamiento, especialmente en los pacientes con TEPT más severo o en los que no han respondido a ninguna de las intervenciones por separado.

Objetivos

Evaluar si la combinación de terapia psicológica y tratamiento farmacológico proporciona un tratamiento más eficaz para el TEPT que cualquiera de estas intervenciones administradas por separado.

Estrategia de búsqueda

Se realizaron búsquedas en los Registros Especializados de Ensayos Controlados del Grupo Cochrane CCDAN (CCDANCTRStudies y CCDANCTRReferences) hasta junio de 2010. También se examinó la sección de referencias de los estudios incluidos y varios resúmenes de congresos.

Criterios de selección

Se incluyó a pacientes de cualquier edad o sexo, con TEPT crónico o de aparición reciente como resultado de cualquier tipo de evento relevante a los criterios de diagnóstico. Se incluyó una combinación de cualquier terapia psicológica y tratamiento farmacológico y se la comparó con lista de espera, placebo, tratamiento estándar o cualquier intervención sola. La medida de resultado primaria fue el cambio en la gravedad total de los síntomas del TEPT. Otras medidas de resultado incluyeron cambios en el funcionamiento, depresión y síntomas de ansiedad, intentos de suicidio, uso de sustancias, abandonos y costes.

Obtención y análisis de los datos

Dos o tres revisores seleccionaron los ensayos, evaluaron su “riesgo de sesgo” y extrajeron los datos del ensayo y los datos de resultado de forma independiente. Para el metanálisis se utilizó un modelo de efectos fijos. El riesgo relativo se utilizó para resumir los resultados dicotómicos y la diferencia de medias y la diferencia de medias estandarizada se utilizaron para resumir las medidas continuas.

Resultados principales

Cuatro ensayos fueron elegibles para su inclusión, uno de ellos (n =24) se realizó en niños y adolescentes. Todos usaron un ISRS y exposición prolongada o una intervención cognitivoconductual. Dos ensayos compararon el tratamiento combinado con el tratamiento farmacológico y dos compararon el tratamiento combinado con el tratamiento psicológico. Sólo dos ensayos informaron una puntuación total de los síntomas del TEPT y dichos datos no pudieron ser combinados. No hubo pruebas sólidas para mostrar si hubo diferencias entre el grupo que recibió intervenciones combinadas en comparación con el grupo que recibió terapia psicológica (diferencia de medias 2,44; IC del 95%: −2,87; 7,35 un estudio, n = 65) o tratamiento farmacológico (diferencia de medias −4,70, IC del 95%: −10,84 a 1,44; un estudio, n = 25). Los revisores no informaron ninguna diferencia significativa entre los grupos de intervención combinada o simple en los otros dos estudios. Hubo muy pocos datos informados en cuanto a otras medidas de resultado, y en ningún caso se informaron diferencias significativas.

Conclusiones de los autores

No hay pruebas disponibles suficientes para apoyar o refutar la efectividad de la terapia psicológica y el tratamiento farmacológico combinados en comparación con cualquiera de estas intervenciones por separado. Se necesitan urgentemente amplios ensayos controlados con asignación aleatoria adicionales.

Traducción

Traducción realizada por el Centro Cochrane Iberoamericano

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