Abstract
BackgroundIn the treatment of PTSD, meta-analyses suggest comparable efficacy of cognitive behavioural therapies and various trauma focused treatments, but results for other treatments are inconsistent. One meta-analysis found no differences for bona fide therapies, but was critizised for overgeneralization and a biased study sample and relied on an omnibus test of overall effect size heterogeneity that is not widely used.MethodsWe present an updated meta-analysis on bona fide psychotherapies for PTSD, contrasting an improved application of the omnibus test of overall effect size heterogeneity with conventional random-effects meta-analyses of specified treatment types against all others. Twenty-two studies were eligible, reporting 24 head-to-head comparisons in randomized controlled trials of 1694 patients.ResultsHead-to-head comparison between trauma focused and non-trauma focused treatments revealed a small relative advantage for trauma focused treatments at post-treatment (Hedges’ g = 0.14) and at two follow-ups (g = 0.17, g = 0.23) regarding PTSD symptom severity. Controlling and adjusting for influential studies and publication bias, prolonged exposure and exposure therapies (g = 0.19) were slightly more efficacious than other therapies regarding PTSD symptom severity at post-treatment; prolonged exposure had also higher recovery rates (RR = 1.26). Present-centered therapies were slightly less efficacious regarding symptom severity at post-treatment (g = −0.20) and at follow-up (g = −0.17), but equally efficacious as available comparison treatments with regards to secondary outcomes. The improved omnibus test confirmed overall effect size heterogeneity.ConclusionsTrauma focused treatments, prolonged exposure and exposure therapies were slightly more efficacious than other therapies in the treatment of PTSD. However, treatment differences were at most small and far below proposed thresholds of clinically meaningful differences. Previous null findings may have stemmed from not clearly differentiating primary and secondary outcomes, but also from a specific use of the omnibus test of overall effect size heterogeneity that appears to be prone to error. However, more high-quality studies using ITT analyses are still needed to draw firm conclusions. Moreover, the PTSD treatment field may need to move beyond a focus primarily on efficacy so as to address other important issues such as public health issues and the requirements of highly vulnerable populations.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-016-0979-2) contains supplementary material, which is available to authorized users.
Highlights
In the treatment of post-traumatic stress disorder (PTSD), meta-analyses suggest comparable efficacy of cognitive behavioural therapies and various trauma focused treatments, but results for other treatments are inconsistent
With regards to PTSD, existent meta-analytical reviews suggest that cognitive behavioural therapy (CBT), trauma focused CBT (TFCBT), exposure therapies, and eye movement desensitization reprocessing (EMDR) are effective, but results of non-trauma focused therapies like hypnotherapy, psychodynamic therapy or supportive therapy are heterogeneous and inconsistent, meaning either that they are less effective or were yet not sufficiently examined to prove their efficacy [11,12,13,14,15,16,17,18,19,20,21]
Eligibility Eligibility criteria for studies to be included in this metaanalysis were: (1) a randomized and controlled study design (RCT), investigating the relative efficacy of (2) at least two bona fide psychotherapies; (3) therapies needed to be conducted in two or more sessions; (4) participants were adults that were (5) diagnosed with PTSD according to the valid edition of the DSM at the time of the respective study (DSM-III or DSM-IV); (6) PTSD symptom severity was assessed with self-report or clinician rating
Summary
In the treatment of PTSD, meta-analyses suggest comparable efficacy of cognitive behavioural therapies and various trauma focused treatments, but results for other treatments are inconsistent. Whereas early extensive meta-analyses did not make precise distinctions between disorders and outcomes [3, 4], but included different psychotherapies for different disorders, critics warned against overgeneralization, undifferentiated methodology, and confounded results [5,6,7,8] Empirical justification for this critique was provided, for example, in the treatment of anxiety disorders: there, an advantage of cognitive behavioural therapy (CBT) over relaxation treatment pertained in panic disorder but not generalized anxiety disorder, and was evident in primary, symptomoriented, outcomes, but not in secondary, more general, outcomes [9, 10]. The status of supportive therapies appears currently unclear, leaving the question open whether specific techniques really make any difference over common factors [10, 22]
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