Transcript Rob Williams Presentation - PTSD Psychotherapiesx

A Summary of a Systematic Review
Robert Williams, LCSW, BCD
University of Utah
Study Details

 Bisson J, Andrew M. Psychological treatment of posttraumatic stress disorder (PTSD). Cochrane Database
of Systematic Reviews 2007, Issue 3. Art. No.:
CD003388. Retrieved Jan 25, 2012 from
www.onlinelibrary.wiley.com
Objectives

To perform a systematic review of
randomized controlled trials of all
psychological treatments following the
guidelines of The Cochrane Collaboration.
Plain Language
Summary

 There is evidence that individual trauma focused CBT,
EMDR, Stress Management and group TFCBT are
effective treatments of PTSD.
 Other non-trauma focused psychological treatments did
not reduce PTSD symptoms as significantly
 Some evidence that individual TFCBT and EMDR are
superior to stress management at 2 to 5 months post
treatment and TFCBT and EMDR are superior to other
therapies
 Trauma focused treatments are more effective than nontrauma focused treatments.
Search Strategy
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 Searched the Cochrane Optimal RCT search strategy
using the following words: PTSD, Trauma,
Cognitive, Behavioural, exposure, EMDR,
psychological, psychotherapy, psychodynamic,
stress inoculation, relaxation, anxiety management
 Databases: Medline, clinpsych, psychlit, Embase, Pilots
(a specialized PTSD database maintained by theNational
PTSDCentrein the USA), Trials Register of the Cochrane
Depression, Anxietyand Neurosis Group, lilacs, psynebs,
sociofile.
Search Strategy (cont)

 Hand Search of Journal of Traumatic Stress, ISTSS
Treatment Guidelines (Foa 200)
 Reference lists of studies identified in the search
 Internet Search of known websites and discussion for a
 Personal communication with NICE guidelines
development group who shared their searches and
communication with 38 researchers
 Abstracts/Dissertations from the meetings of the
European International Societies of Traumatic Stress
Studies
Inclusion Criteria
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 All RCTs focusing on considering one or more
defined psychological treatments to reduce PTSD
symptoms.
 All adult individuals suffering from traumatic stress
symptoms at least 70% diagnosed with PTSD
according to DMS or ICD criteria
 There was no criteria for severity of symptoms
 Multiple Interventions were considered
Inclusion Criteria
Intervention Types Included

 Individual Trauma Focused CBT
 Includes Exposure Therapies
 Stress management/relaxation
 TFCBT Group Therapy
 Non Trauma focused CBT group therapy
 Other psychological Treatment
 EMDR
 Wait list/usual care
Inclusion Criteria
Outcome Measure

 Primary measure was severity of clinician rated
traumatic stress symptoms using a standardized
measure such as the Clinician Administer PTSD
Symptom Scale (Blake 1995)
 Other Measures included:
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Pt administered scales
Severity of anxiety scales
Droupout rates
PTSD diagnosis after treatment
Any adverse effects (increased symptomology)
Exclusion Criteria

 Assessed methodological quality using standard
approach described in Cochrane Handbook.
 Utilized a 23 criteria scale with scores between 0-2
total maximum score 46.
 Double reviewed disagreements discussed between
reviewers regarding study quality
 Cutoff score was not identified in the review
Reasons for Exclusion

 Did not satisfy inclusion criteria
 Less than 3 months follow up following trauma
 Treatment for anger only
 Relaxation treatments with no comparison
 Comparison of two CBT techniques only
PRISMA Search Flow Diagram

 There was no search flow diagram included in this
Systematic review.
 There was no information on the number of studies
identified and screened.
 Inclusion & exclusion numbers were acquired by
counting studies noted in tables.
 11 studies were excluded.
 41studies were included in this systematic review.
Data Synthesis

 Data was summarized a pooled effects calculated
using RevMan 4.1 software
 Continuous outcomes were analyzed as standard
mean differences.
 Data were pooled using fixed effects meta-analysis
except were heterogeneity was present
 Heterogeneity was assessed with both the I Squared
test and the chi-squared test of heterogeneity.
Statistical Analysis

 To achieve meaningful results as non-trauma
focused group CBT, hypnotherapy, psychodynamic
therapy and supportive counseling all had only one
trial they were grouped into a group called other
therapies.
 The number of statistical analyses run was immense
 Therapy groups were broken into subgroups by type
of outcome measurement
 Comparisons were then made of internal efficacy
and comparison to other treatment modalities
Biases

 Potential Publication bias was noted by the reviewers
 All of the studies in this review were published or accepted for
publication
 Potential effects of this bias were explored using funnel plots.
 Smaller studies may tend to report larger between TFCBE and
waitlist/usual care
 Both suggest an absence of studies demonstrating no difference
or a difference in favor of the waitlist/usual care
 Due to greater likelihood of publication of positive studies it is
possible true difference between groups is smaller than
suggested by this review
Risk of Bias

Well completed
Minor errors/
Not explained
Randomization
7
26
Allocation
Concealment
1
27
Blinding
20
Loss to follow up
11
Inadequate
Protections
6
13
19
3
Results
Trauma Focused Cognitive Behavioral Therapy
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 There was good evidence TFCBT was better than
wait list/usual care
 Some evidence TFCBT was more effective than nontrauma focused therapies
 TFCBT was significantly better than other therapies
and than stress management at follow up
Results
Stress Management

 Evidence that stress management is better than wait
list in reducing PTSD symptoms and symptoms of
anxiety and depression
 Based on two studies with small sample size
Results
Other Therapies

 There was no difference between other therapies and
waitlist/usual care on main outcome measure
 Care recipients did fare better on self report
traumatic stress and anxiety measure
 Did not do as well with TFCBT and Stress
Managment
Results
Group TFCBT
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 Evidence group TFCBT was better than waitlist care
as usual
 This was based on one study with small sample
size
 No difference between Group TFCBT and nontrauma focuses CBT
Results
EMDR

 Evidence that EMDR was better than waitlist/care as
usual in reducing traumatic stress symptoms and
additionally symptoms associated with depression and
anxiety
 Included studies had small sample size and two lacked
randomization concealment
 As with TFCBT results may be stronger than suggested
because of ongoing contact with wait list group
 Clinician rated traumatic stress represents a strong
positive effect size however self reported PTSD symptom
severity did not reach statistical significance
Author’s Conclusion
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 Psychological treatment can reduce traumatic stress
symptoms
 TFCBT and EMDR have best evidence for efficacy
 Some limited evidence stress management is
effective
 More limited evidence that non trauma focused
psychological treatments are effective
 Drop-out from treatment is an issue with currently
available treatment
Author’s Conclusion
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 Further well designed studies of psychological
treatment are required that consider boundary issues
 Large EMDR trials are required
 There is a need for more treatment comparison trials
 Further trial should enforce stronger quality control
of intervention and control groups
 Role of psychological treatment in combination and
as an alternative to medication is unclear
Questions/Concerns
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 Basis for Comparison
 Differing kinds of therapies were grouped. How
effective were the groupings.
 Is mean difference the best statistical method?
Questions?
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References

 Bisson J, Andrew M. Psychological treatment of posttraumatic stress disorder (PTSD). Cochrane Database
of Systematic Reviews 2007, Issue 3. Art. No.:
CD003388. Retrieved Jan 25, 2012 from
www.onlinelibrary.wiley.com
