Meta-Analysis & Scorecard for Psychotherapy for Military-Related PTSD

Researchers from New York University, Boston University, the Boston VA Hospital and the Walter Reed Army Institute of Research examined the effectiveness of psychotherapies for PTSD in military and veteran populations. First-line psychotherapies most often recommended for PTSD consist mainly of "trauma-focused" psychotherapies that involve focusing on details of the trauma or associated cognitive and emotional effects.

The investigators searched PubMed, PsycINFO, and PILOTS for randomized clinical trials (RCTs) of individual and group psychotherapies for PTSD in military personnel and veterans, published from January 1980 to March 1, 2015.

They also searched reference lists of articles, selected reviews, and meta-analyses. Of 891 publications initially identified, 36 were included.

Two trauma-focused therapies, cognitive processing therapy (CPT) and prolonged exposure were found to be the most frequently studied psychotherapies for military-related PTSD. Five RCTs of CPT (481 patients) and 4 RCTs of prolonged exposure (402 patients) met the inclusion criteria.

Focusing on intent-to-treat outcomes, within-group post-treatment effect sizes for CPT and prolonged exposure were large (Cohen d range, 0.78-1.10). CPT and prolonged exposure also outperformed waitlist and treatment-as-usual control conditions.

Forty-nine percent to 70% of participants receiving CPT and prolonged exposure attained clinically meaningful symptom improvement (defined as a 10- to 12-point decrease in interviewer-assessed or self-reported symptoms).

However, mean post-treatment scores for CPT and prolonged exposure remained at or above clinical criteria for PTSD, and approximately two-thirds of patients receiving CPT or prolonged exposure retained their PTSD diagnosis after treatment (range, 60%-72%).

CPT and prolonged exposure were marginally superior compared with non-trauma-focused psychotherapy comparison conditions.

The meta-analysis concludes that in military and veteran populations, trials of the first-line trauma-focused interventions CPT and prolonged exposure have shown clinically meaningful improvements for many patients with PTSD.

However, non-response rates have been high, many patients continue to have symptoms, and trauma-focused interventions show only marginally superior results compared with active control conditions.

The investigators conclude that there is a need for improvement in existing PTSD treatments and for the development and testing of novel evidence-based treatments, both trauma-focused and non-trauma-focused

Citation: Steenkamp MM1, Litz BT2, Hoge CW3, Marmar CR1. Psychotherapy for Military-Related PTSD: A Review of Randomized Clinical Trials. JAMA. 2015 Aug 4;314 (5): pp. 489-500. doi: 10.1001/jama.2015.8370.

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