Psychological interventions for adult PTSD: A network and pairwise meta-analysis of short and long-term efficacy, acceptability and trial quality

A large number of randomized controlled trials (RCTs) on psychological interventions for adult posttraumatic stress disorder (PTSD) have been published. We aimed at providing a comprehensive quantitative summary covering short and long-term efficacy, acceptability and trial quality. We conducted systematic searches in bibliographical databases to identify RCTs examining the efficacy (standardized mean differences in PTSD severity, SMDs) and acceptability (relative risk of all-cause dropout, RR) of trauma-focused cognitive behaviour therapy (TF-CBT), Eye Movement Desensitization and Reprocessing (EMDR), other trauma-focused psychological interventions (other-TF-PIs) and non-trauma-focused psychological interventions (non-TF-PIs) compared to each other or to passive or active control conditions. Hundred-fifty-seven RCTs met inclusion criteria comprising 11,565, 4,830 and 3,338 patients at post-treatment assessment, ≤ 5 months follow-up and > 5 months follow-up, respectively. TF-CBT was by fore the most frequently examined intervention. We performed random effects network meta-analyses (efficacy) and pairwise meta-analyses (acceptability). All therapies produced large effects compared to passive control conditions (SMDs ≥ 0.80) at post-treatment. Compared to active control conditions, TF-CBT and EMDR yielded medium treatment effects (SMDs ≥ 0.50 < 0.80), and other-TF-PIs and non-TF-PIs yielded small treatment effects (SMDs ≥ 0.20 < 0.50). Interventions did not differ in their short-term efficacy, yet TF-CBT was more effective than non-TF-PIs (SMD = 0.17) and other-TF-PIs (SMD = 0.30). Results remained robust in sensitivity and outlier-adjusted analyses. Similar results were found for long-term efficacy. Interventions also did not differ in terms of their acceptability, except for TF-CBT being associated with a slightly increased risk of dropout compared to non-TF-PIs (RR=1.36; 95% CI: 1.08-1.70). In sum, interventions with and without trauma focus appear effective and acceptable in the treatment of adult PTSD. TF-CBT is by far the most well-researched intervention and yields the highest efficacy. However, TF-CBT appears somewhat less acceptable than non-TF-PIs.