A Multidimensional Meta-Analysis of Psychotherapy for PTSD
Bradley R, Greene J, Russ E, Dutra L and Westen D;
Commented by , 24 Feb 2005
Background
Post-Traumatic Stress Disorder is a highly prevalent disorder for which different types of psychotherapy are available, either as stand-alone treatment or in combination with pharmacotherapy. Although the efficacy of specific types of psychotherapy has been demonstrated in clinical trials, there still is a considerable lack of information on a number of issues, including in particular questions about which patients are more likely to respond, or what type of therapy is more effective than another.
Aims of the study
To investigate the efficacy of psychotherapy in general, and of specific types of psychotherapy in particular, for PTSD, using data from controlled clinical trials.
Method
A meta-analysis of studies published between 1980 and 2003 on psychotherapy in the treatment of PTSD. To be included, studies had to meet the following requirements:
- Test a specific psychotherapeutic treatment
- Involve a control condition
- Use a validated measure of PTSD symptoms
- Use a randomised design
- Have at least 10 patients in each experimental group
In addition to reports on effect sizes for each type of active treatment relative to wait-list control and supportive control conditions, the authors analysed data on inclusion, exclusion and completion criteria and rates, recovery and improvement rates, and follow-up.
Results
26 studies met the requirements listed above. The studies included 44 treatment conditions: 13 exposure-based therapies, 5 CBT treatments other than exposure, 9 treatments combining CBT and exposure, 10 EMDR, and 7 other psychotherapy conditions.
Professor Pull's comments
As shown by the results of this study, various forms of psychotherapy, in particular CBT as well as EMDR, are efficacious in the treatment of PTSD.
The multidimensional meta-analysis does reveal, however, that these results cannot be applied directly to patients in the community. In fact, currently available information on the efficacy of psychotherapy for PTSD must be viewed critically, owing to several important factors that limit the generalizability of the findings:
- Half of the studies excluded potential participants for suicide risk
- Most of the studies reviewed did not provide data on comorbidity
- At post-treatment, and across treatments, the average patient still had considerable residual symptoms
- Only ten of the studies included follow-up evaluations at 6months, and only two studies provided follow-up data at 12 months post-treatment</>
- There are problems related to some of the criteria for successful outcome, e.g., to the criterion “does no longer meet criteria for PTSD”, in that patients may no longer meet criteria for PTSD when there is a change in only one or two symptoms
Conclusion
This is a highly interesting report on a complex topic. It shows that there are, at present, psychotherapeutic interventions that are highly effective in PTSD. It also reveals, however, a number of shortcomings in the best studies that are currently available on the efficacy of psychotherapy for PTSD, and thus highlights the fact that there is a need for even better controlled studies in the field.