Psychological interventions for adult PTSD: A network and pairwise meta-analysis of short and long-term efficacy, acceptability and trial quality

Abstract

While dozens of randomized controlled trials (RCTs) have examined psychological interventions for adult posttraumatic stress disorder (PTSD), no network meta-analysis has comprehensively integrated their results for all interventions and both short and long-term efficacy. We conducted systematic searches in bibliographical databases to identify RCTs comparing the efficacy (standardized mean differences in PTSD severity, SMDs) and acceptability (relative risk of all-cause dropout, RR) of trauma-focused cognitive behaviour therapy (TF-CBT), Eye Movement Desensitization and Reprocessing (EMDR), other trauma-focused psychological interventions (other-TF-PIs) and non-trauma-focused psychological interventions (non-TF-PIs) compared to each other or to passive or active control conditions. Hundred-fifty RCTs met inclusion criteria comprising 11,282, 4,443 and 3,167 patients at post-treatment assessment, ≤ 5 months follow-up and > 5 months follow-up, respectively. By far the most data exist for TF-CBT. We performed random effects network meta-analyses (efficacy) and pairwise meta-analyses (acceptability). All therapies produced large effects compared to passive control conditions (SMDs ≥ 0.80) at post-treatment. Compared to active control conditions, TF-CBT and EMDR were moderately more effective (SMDs ≥ 0.50 < 0.80), and other-TF-PIs and non-TF-PIs were slightly more effective (SMDs ≥ 0.20 < 0.50). Interventions did not differ in their short-term efficacy, yet TF-CBT was more effective than non-TF-PIs (SMD = 0.14). Results remained robust in sensitivity and outlier-adjusted analyses. Similar results were found for long-term efficacy. Interventions also did not differ in terms of their acceptability, except for TF-CBT being associated with a slightly increased risk of dropout compared to non-TF-PIs (RR=1.34; 95% CI: 1.05-1.70). Interventions with and without trauma focus appear effective and acceptable in the treatment of adult PTSD with most certainty for TF-CBT, which, however, appears somewhat less acceptable than non-TF-PIs.