Impacts of Internet-Based Interventions for Veterans With PTSD: A Systematic Review and Meta-Analysis

Abstract

Background: Veterans who did not seek and complete treatment as intended have been shown to have an elevated risk of experiencing and being exposed to post-traumatic stress disorder (PTSD). Internet-based interventions (IBIs) provide more confidentiality and fewer treatment barriers, and they are regarded as potential treatments to reduce PTSD in veterans. However, the effects of IBI for veterans with PTSD are inconclusive.Objectives: IBI is defined as any internet-based series of psychosocial interventions, of which the internet works as a way of delivery. Psychosocial content and reduction of PTSD symptoms in veterans have been recognized as two core elements of this intervention. This study aimed to (1) examine the effects of IBI on veterans’ PTSD outcomes and (2) distinguish between the elements of IBI that play an important role for veterans with PTSD.Methods: Web of Science, PubMed, EMBASE, PsycINFO, Cochrane, Wanfang Data, CNKI, and CQVIP databases were searched for randomized controlled trials (RCT) in IBI programs for veterans with PTSD, covering all studies in English and Chinese published from January 1990 to November 2020. Also, related studies tracking citations were identified. Studies met the following inclusion criteria of (1) being RCTs; (2) containing IBI in the full text; (3) having IBI conducted on veterans as participants; and (4) being on PTSD. All processes followed PRISMA. The risk of bias of the studies was assessed by the Cochrane Systematic Review Handbook. The confidence of outcomes of this review was valued according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation). The meta-analysis was done by RevMan 5.13. Two teams of reviewers independently searched the literature, made the assessment, and extracted the data.Results: A total of 1,493 citations were identified after initial searching, of which the full texts of 66 studies were screened. Eventually, six RCT studies met the inclusion criteria. Beneficial effects of IBI were found on the overall PTSD outcome (−0.29; 95% CI–0.48 to −0.11, p<0.01). Particularly, IBI based on cognitive behavioral therapy (CBT) with peer support was found to be effective for PTSD outcomes (−0.36; 95% CI–0.61 to −0.11, p<0.01). The subgroup analysis demonstrated that scores of PTSD outcome measured by a PCL (PTSD Checklist) decreased to an average score of 0.38 (95% CI –0.60 to −0.15, p=0.001). The intervention had a positive effect on the PTSD outcome on veterans with comorbid psychological disorders (−0.30; 95% CI –0.61 to −0.11, p<0.01). Overall, the six studies included were evaluated with a low risk of bias, and the outcomes of the meta-analysis were proven with high confidence.Conclusion: On the whole, IBIs have a positive effect on the overall PTSD outcome of veterans. The results encouraged us to focus on IBI with CBT with peer support for veterans, on specific instruments for veterans with PTSD, and on veterans with comorbid psychological disorders. This study, however, has limits. Only six studies with a Western population were included, which might result in cultural bias on IBI effects. In future, more high-qualified research and diverse cultural background of RCTs is needed to prove the effectiveness of IBI on veterans with PTSD.

A meta-analysis of internet-based cognitive behavioral therapy for military and veteran populations

“…[ 13 , 14 ] Further, this population exhibits distinctions in symptom presentation and comorbidities [ 15 ], and is often less responsive [ 16 ], or differentially responsive [ 17 ] to mental health treatments compared to general populations. Interestingly, research has found iCBT to be an effective treatment for insomnia [ 18 ] and PTSD [ 7 ] within military and veteran populations. However, the variability in iCBT study design, as stated above, remain unclear among this population.…”

“…Specifically, in reviewing available meta-analyses conducted on internet-based interventions, only four articles included, or focused on, military populations. [ 7 – 10 ] However, none of the meta-analyses focused specifically on iCBT within a military population or examined effects across various demographics, characteristics of iCBT interventions, and mental and physical outcomes.…”

Assessing the effectiveness of internet-based interventions for mental health outcomes: an umbrella review

“…Internet-based interventions (IBIs) are any psychological interventions facilitated via the internet, which serves as a medium of delivery. 1 This not only encompasses methods such as telecommunication (eg, phone calls, text messages) but also includes a range of internet-facilitated therapies such as online psychoeducational courses, cognitive–behavioural therapy (CBT), mobile applications, emails, video conferencing, social media platforms and online chat systems. 2 While a substantial number of individuals with mental health challenges still opt for face-to-face (FTF) treatment, there is an emerging preference for computer-assisted alternatives.…”

“…However, when CBT was amalgamated with other therapies, it exhibited a small effect size (SMD=0.39, 95% CI 0.23 to 0.55). Given the limited number of studies 1 34 47 reporting the efficacy of CBT combined with other therapies (with two studies reporting higher efficacy than standalone CBT and two reporting lower), any related conclusions should be drawn cautiously. Additionally, we were unable to definitively discern which components were most effective when CBT was integrated with other approaches.…”