Prevention and treatment of PTSD: the current evidence base.

Post-traumatic stress disorder is a common condition that affects millions of people across the world. Up to date recommendations based on the best available evidence are vital to prevent and treat this debilitating condition. In this issue, we are bringing together a series of systematic reviews and meta-analyses that underpinned the development of the 2018 International Society for Traumatic Stress Studies Guidelines. The strongest evidence was found for psychological treatments for PTSD, in particular for cognitive behavioural therapy with a trauma focus (CBT-TF)(generic), cognitive processing therapy (CPT), cognitive therapy (CT), eye movement desensitisation and reprocessing (EMDR) and prolonged exposure (PE). For the subgroup of military personnel and veterans, results were less impressive. Dropout from trauma-focused psychological treatments was higher than for other forms of psychological treatment for PTSD in adults. For early interventions, CBT-TF, CT and EMDR were recommended. With regard to pharmacological approaches, a number of them were effective but with a low effect size. Of the pharmacologically assisted psychotherapies, MDMA-assisted psychotherapy was promising. Six complementary and alternative approaches showed emerging evidence. We now have an evidence base for a diverse range of pharmacological, psychological and other approaches that should facilitate their implementation and lead to the more effective management of people affected by traumatic events.

Introduction

The COVID-19 crisis is a timely reminder that, sadly, traumatic experiences are highly prevalent across the world (Kessler et al., 2017) and a major public health issue (Magruder, McLaughlin, & Elmore Borbon, 2017). It is, therefore, essential that we understand how best to help those affected by traumatic events and that effective interventions are available to reduce the psychosocial impact of them.

There has been and is much debate on how best to prevent and treat post-traumatic stress disorder (PTSD). More recently, this debate has extended to include the management of complex PTSD (CPTSD). Since the first International Society for Traumatic Stress Studies (ISTSS) Treatment Guidelines were published in 2000 (Foa, Keane, & Friedman, 2000), there has been an almost exponential growth in the number of prevention and treatment trials conducted. Despite this, it has remained difficult to provide evidence-based recommendations for all prevention and treatment questions, resulting in alternative methods being used to develop evidence-informed recommendations, such as the use of Delphi methodology for the ESTSS TENTS guidelines (Bisson et al., 2010).

The third version of the ISTSS Prevention and Treatment Guidelines (International Society of Traumatic Stress Studies (ISTSS) [Online], 2018a) was published in late 2018 and provide recommendations based on syntheses of data from randomized controlled trials (RCTs). The ISTSS Guidelines were developed through a robust methodological process involving systematic reviews of the literature, meta-analyses of RCT results that addressed specific scoping questions, and then the development of recommendations from the evidence available following an agreed algorithm (Bisson et al., 2019). In the case of CPTSD, the ISTSS Treatment Guidelines Committee determined that, because of definitional issues and the limited availability of appropriate clinical trials, meaningful meta-analyses could not be conducted. Instead, narrative reviews of the current situation were undertaken to facilitate the development of a definitive evidence base to inform future recommendations on the management of CPTSD in children, adolescents and adults (International Society of Traumatic Stress Studies (ISTSS) [Online], 2018b, 2018c).

This special EJPT issue provides readers with an opportunity to read more detailed accounts of the majority of the systematic reviews and meta-analyses that underpin the ISTSS Guideline recommendations for adults and represents a detailed picture of the state of the art with respect to the prevention and treatment at the time this work was completed.

Articles in this issue

Early psychological interventions for adults exposed to trauma (Roberts, Kitchiner, Kenardy, Lewis, & Bisson, 2020). This paper concludes that the quality of the evidence remains low but includes recommendations for cognitive behavioural therapy with a trauma focus (CBT-TF), cognitive therapy and eye movement desensitisation and reprocessing (EMDR) for early treatment.

Psychological treatments for adults with PTSD (Lewis, Roberts, Andrew, Starling, & Bisson, 2020). This paper demonstrates the large increase in RCTs of psychological treatments for adults that allowed individual forms of cognitive behavioural therapy with a trauma focus (CBT-TF) to be evaluated separately in addition to as a family of interventions. Sixteen different treatments received some form of recommendation, CBT-TF (generic), cognitive processing therapy, cognitive therapy, EMDR and prolonged exposure all received the strongest recommendation available, making them the first-line treatments for PTSD.

Psychological treatment for active duty and ex-serving military personnel (Kitchiner, Lewis, Roberts, & Bisson, 2019). This paper provides a sub-analysis of studies included in the psychological treatment paper described above. The results for military personnel and veterans are less impressive than for the population as a whole. The UK’s NICE Guideline (NICE, 2018) decision not to recommend EMDR for veterans is supported by the meta-analyses in this paper although the low number and low quality of the studies available may have impacted this finding.

Dropout from psychological treatment (Lewis, Roberts, Gibson, & Bisson, 2020). The reasons for dropout are multiple and it is important not to equate it solely with tolerability of a treatment, although these issues do seem to be related to a degree. This review found that dropout from trauma-focused psychological treatments was higher than for other forms of psychological treatment for PTSD in adults.

Pharmacological treatment of adults with PTSD (Hoskins et al., 2020). This paper demonstrates strong low effect evidence for a number of pharmacological approaches. Fluoxetine, paroxetine, sertraline and venlafaxine all have good evidence that they reduce PTSD symptoms in adults but the magnitude of improvement appears to be less than that found for the psychological treatments with the best evidence of effect.

Pharmacologically-assisted psychotherapy for adults with PTSD (Hoskins et al., 2020). Although not included in the ISTSS Guidelines, the emergence of MDMA-assisted psychotherapy and other approaches that combine medication and psychological treatment make this an increasingly important area to consider. MDMA-assisted psychotherapy was the most promising of the interventions considered and shown to have emerging evidence of effect.

Non-psychological and non-pharmacological interventions (Bisson, Van Gelderen, Roberts, & Lewis, 2020). The final paper provides an overview of the results of the systematic review and meta-analyses that led to the final group of ISTSS recommendations. There is emerging evidence for six different interventions, including yoga, neurofeedback, transcranial magnetic stimulation and acupuncture. These findings have major clinical and research implications and should encourage more research with respect to complementary and alternative approaches.

Future work

It is hoped that this unique collection of papers will stimulate people working in the field to undertake further research to develop more effective interventions for the prevention and treatment of PTSD by refining existing effective approaches and developing new ones. There are a large number of interventions with emerging evidence of effect that appear to be at a point where further development would help them develop to the next level.

There are also major questions to be answered with respect to how best to effectively implement evidence-based interventions into practice at scale across the world, to maximise global impact and improve the health and wellbeing of people exposed to traumatic events (Olff et al., 2019). Work is ongoing to facilitate this, e.g. through the development of decision aids focused on people with PTSD, to help them navigate the current evidence base and inform decision-making that is right for their needs.