The efficacy of psychological interventions for adult post-traumatic stress disorder following exposure to single versus multiple traumatic events: a meta-analysis of randomised controlled trials.

BACKGROUND: Previous meta-analyses of psychological interventions for adult post-traumatic stress disorder (PTSD) did not investigate whether efficacy is diminished in individuals with PTSD related to multiple (vs single) traumatic events. We aimed to assess whether treatment efficacy would be lower in randomised controlled trials involving multiple-event-related PTSD versus single-event-related PTSD. METHODS: For this meta-analysis, we searched PsycINFO, MEDLINE, Web of Science, and PTSDpubs from database inception to April 18, 2023. Randomised controlled trials involving adult clinical samples (≥70% meeting full PTSD criteria) with adequate size (≥10 participants per arm) were included. We extracted data on trial characteristics, demographics, and outcome data. Random-effects meta-analyses were run to summarise standardised mean differences (Hedges' g). Trials involving 100% of participants with single-event-related PTSD versus at least 50% of participants with multiple-event-related PTSD (ie, associated with ≥two traumatic events) were categorised. Quality of evidence was assessed using the Cochrane criteria. The review protocol was registered in PROSPERO (CRD42023407754). FINDINGS: Overall, 137 (85%) of 161 randomised controlled trials were included in the quantitative synthesis, comprising 10 684 participants with baseline data and 9477 with post-treatment data. Of those randomly assigned, 5772 (54%) of 10 692 participants identified as female, 4917 (46%) as male, and three (<1%) as transgender or other. 34 (25%) of 137 trials exclusively involved women, 15 (11%) trials exclusively involved men, and the remainder were mixed samples. Mean age across the trials was 40·2 years (SD 9·0) ranging from 18·0 years to 65·4 years. 23 (17%) of 137 trials involved participants from low-income and middle-income countries (23 [17%] of 137). Data on ethnicity were not extracted. At treatment endpoint, psychological interventions were highly effective for PTSD when compared with passive control conditions in both samples with single-event-related PTSD (Hedges' g 1·04 [95% CI 0·77-1·31]; n=11; I2=43%) and multiple-event-related PTSD (Hedges' g 1·13 [0·90-1·35]; n=55, I2=87%), with no efficacy difference between these categories (p=0·48). Heterogeneity between studies was substantial but outlier-corrected analysis yielded similar results. Moderate-sized effects were found compared with active control conditions with no significant difference between single-trauma and multiple-trauma trials. Results were robust in various sensitivity analyses (eg, 90% cutoff for multiple-trauma trials) and analyses of follow-up data. The quality of evidence was moderate to high. INTERPRETATION: Contrary to our hypothesis, we found strong evidence that psychological interventions are highly effective treatments for PTSD in patients with a history of multiple traumatic events. Results are encouraging for clinical practice and could counteract common misconceptions regarding treatment and treatment barriers. FUNDING: None.

Efficacy of imagery rescripting in treating mental disorders associated with aversive memories - An updated meta-analysis.

Imagery rescripting (ImRs) is frequently applied to treat different psychological complaints. We conducted an updated meta-analysis based on randomised controlled trials on the efficacy of ImRs for mental disorders associated with aversive memories. Medline, PsycInfo, and Web of Science were searched up to May 2023. Seventeen trials were included with a total of 908 participants (417 in the ImRs condition), suffering from posttraumatic stress disorder, anxiety disorders, depression, or eating disorders. Random effect models yielded an overall effect of g = 0.68 (95 % CI 0.18 to 1.18; k = 7) compared to passive controls (mostly waitlist). The effect compared to (prolonged) exposure, cognitive restructuring, and EMDR was non-significant (g = -0.01; 95 % CI -0.18 to 0.15; k = 11). Follow-up assessments indicated a long-term treatment effect. Results suggest that ImRs can effectively treat a variety of psychological disorders and produce similar treatment effects as evidence-based interventions. Limitations include the bounded number of included trials for each mental disorder. The meta-analysis was registered on PROSPERO (CRD42020220696) and received no funding.

The efficacy and acceptability of psychological interventions for adult PTSD: A network and pairwise meta-analysis of randomized controlled trials.

OBJECTIVE: A comprehensive quantitative summary of the efficacy and acceptability of psychological interventions (PIs) for adult posttraumatic stress disorder (PTSD) is lacking. METHOD: We conducted a systematic literature search to identify randomized controlled trials (RCTs) examining the efficacy and acceptability (all-cause dropout) of psychological interventions (i.e., trauma-focused cognitive behavior therapy [TF-CBT], eye movement desensitization and reprocessing [EMDR], other trauma-focused interventions and non-trauma-focused interventions). RESULTS: One hundred fifty-seven RCTs were included comprising 11,565 patients. Most research (64% of RCTs) accumulated for TF-CBT. In network meta-analyses, all therapies were effective when compared to control conditions. Interventions did not differ significantly in their efficacy. Yet, TF-CBT yielded higher short- (g = 0.17, 95% CI [0.03-0.31], number of comparisons kes = 190), mid- (i.e., ≤5 months posttreatment, g = 0.23, 95% CI [0.06-0.40], kes = 73) and long-term efficacy (i.e., >5 months posttreatment, g = 0.20, 95% CI [0.04-0.35], kes = 41) than non-trauma-focused interventions. There was some evidence of network inconsistencies, and heterogeneity in outcomes was large. In pairwise meta-analysis, slightly more patients dropped out from TF-CBT than non-trauma-focused interventions (RR = 1.36; 95% CI [1.08-1.70], kes = 22). Other than that, interventions did not differ in their acceptability. CONCLUSIONS: Interventions with and without trauma focus are effective and acceptable in the treatment of PTSD. While TF-CBT yields the highest efficacy, slightly more patients discontinued TF-CBT than non-trauma-focused interventions. Altogether, the present results align with results of most previous quantitative reviews. Yet, results need to be interpreted with caution in light of some network inconsistencies and high heterogeneity in outcomes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Are psychological interventions for adult PTSD more efficacious and acceptable when treatment is delivered in higher frequency? A meta-analysis of randomized controlled trials.

BACKGROUND: Two systematic reviews indicated that higher treatment frequency of psychological interventions for adult PTSD may lead to higher efficacy and less dropout. Yet, a quantitative review is missing. METHODS: We conducted a thorough systematic literature search and included trials meeting the following criteria: a) random allocation, 2) PTSD was primary treatment focus, 3) ≥ 70% interview-based PTSD rate 4) mean age ≥ 18 years, and 5) N ≥ 20. Treatment session frequency was analyzed dichotomously (< 1.5 vs. ≥ 1.5 sessions/week) and continuously (sessions per week & minutes per week). RESULTS: A total of 160 RCTs with data from 10,556 patients were included. Analyses yielded similar treatment efficacy irrespective of treatment frequency definitions and whether differential efficacy was estimated directly via head-to-head trials or indirectly via comparisons to the same comparison group. Intense (≥ 1.5 sessions/week) vs. standard (< 1.5 sessions/week) delivery was, however, associated with significantly lower dropout rates (as a proxy for acceptability) for trauma-focused interventions (18.64% vs 11.54%, respectively, p = .024), but not for non-trauma-focused interventions. CONCLUSIONS: We found no evidence for differential treatment efficacy of intense vs. standard psychotherapies for adult PTSD. Evidence for increased acceptability was found for intense vs. standard trauma-focused interventions.

Efficacy of psychological interventions for PTSD in distinct populations - An evidence map of meta-analyses using the umbrella review methodology.

We aimed at mapping the meta-analytic evidence base on the efficacy of psychological treatments for posttraumatic stress disorder (PTSD) in specific populations. We conducted a systematic search until January 2022 in MEDLINE, PsycINFO, PTSDpubs, Web of Science, and the Cochrane Database of Systematic Reviews for meta-analyses of randomized controlled trials. We contrasted all eligible meta-analyses irrespective of overlapping datasets to present a comprehensive overview of the state of research. Reporting quality was assessed using the AMSTAR 2 tool and certainty of evidence was assessed using established umbrella review criteria. Nine meta-analyses with distinct adult populations (51 unique trials) and four with children and adolescents (24 unique trials) were included. Reporting quality of meta-analyses was heterogeneous with risk of bias assessment being rated lowest. The certainty of evidence on the efficacy of psychological interventions for adult populations was thoroughly weak because of small samples and large heterogeneity. In war- and conflict-affected youth, the certainty of evidence was suggestive. Our review highlights the need to improve quality of meta-analyses on treatment efficacy for PTSD. More importantly, however, the findings demonstrate the need for new large-scale trials on the efficacy of treatments for PTSD in distinct populations in order to increase certainty of evidence and to identify potential differences in treatment responses.

Culturally adapted cognitive behavioural group therapy for mental disorders in refugees plus problem solving training (ReTreat): study protocol for a multicentre randomised controlled trial.

INTRODUCTION: Since a high proportion of refugees in Germany suffer from mental disorders, culturally adapted treatments are needed that target a broad range of symptoms. There is much evidence for the efficacy of culturally adapted cognitive behavioural therapy (CA-CBT). Given the promising results of CA-CBT, the combination with problem solving training (CA-CBT+) represents a novel approach that potentially improves the refugees' ability to cope actively with psychosocial problems. This randomised controlled trial evaluates the efficacy of 12-session outpatient CA-CBT+ compared with to treatment as usual (TAU) in a sample of refugees suffering from at least one DSM-5 disorder. METHODS AND ANALYSIS: The present study will be carried out as two-group randomised trial with 1:1 individual allocation to either (1) culturally adapted cognitive behavioural therapy in a group setting (CA-CBT+) or (2) TAU. The study takes place at four sites in Germany, randomising in total 138 adult refugees with at least one primary DSM-5 diagnosis to the treatment conditions. In CA-CBT+ the patients receive 12 sessions of 120 min duration over the course of 12 weeks providing psychoeducation, meditation and other techniques of emotional regulation, stretching and problem solving training. The primary outcome is treatment response operationalised by a clinically significant change in General Health Questionnaire (GHQ-28) score. Follow-up visits will take place 3 and 9 months after the end of the intervention. Secondary outcomes include changes in psychopathological symptoms, somatic symptoms and quality of life. Intention-to-treat analysis will be performed. Adverse and serious adverse events will be analysed. Further, healthcare usage and economic outcomes will be assessed and analysed. Primary and secondary outcomes will be analysed using appropriate statistical methods. ETHICS AND DISSEMINATION: The study has been approved by the Ethics Commission of the German Psychological Society (ref: StangierUlrich2019-1018VA). Results will be disseminated via presentations, publication in international journals, and national outlets for clinicians. Furthermore, intervention materials will be available, and the existing network will be used to disseminate and implement the interventions into routine healthcare. TRIAL REGISTRATION NUMBER: DRKS00021536.

The relationship of trauma-related guilt with PTSD symptoms in adult trauma survivors: a meta-analysis.

Posttraumatic stress disorder (PTSD) is a severe condition that is associated with trauma-related guilt. We aimed at providing a comprehensive quantitative systematic review on the relationship between trauma-related guilt and adult PTSD. Database searches in Medline, PsycINFO, PTSDpubs and Web of Knowledge resulted in the inclusion of 163 eligible studies with a total of 35 020 trauma survivors. The studies reported on 157 cross-sectional and 19 longitudinal data points. Overall, we included 135 studies not included in previous meta-analyses. Random-effect models yielded a moderate cross-sectional correlation (r = 0.38, 95% CI 0.35-0.42, p < 0.001, I2 = 90.3%) and a small to moderate predictive correlation (r = 0.21, 95% CI 0.13-0.29, p < 0.001, I2 = 66.7%). The association appeared to be stable over time and was robust to sensitivity analyses. All symptom clusters significantly correlated with guilt. No effects were found for military v. civilian populations or clinical v. non-clinical samples. Effects were smaller for high-quality studies and larger for instruments based on DSM-5. Further significant moderators were type of guilt measure and trauma type. The largest association was found among participants reporting war-related trauma (r = 0.44, 95% CI 0.36-0.51) and the smallest among survivors of motor-vehicle accidents (r = 0.18, 95% CI 0.02-0.33). The results underpin the role of trauma-related guilt in the onset and maintenance of PTSD symptoms, which have important clinical implications. Future studies should further explore the change interactions of guilt and PTSD symptoms.

A network meta-analysis of psychosocial interventions for refugees and asylum seekers with PTSD.

INTRODUCTION: Refugees and asylum seekers are vulnerable to common mental disorders, including post-traumatic stress disorder (PTSD). Using a network meta-analysis (NMA) approach, the present systematic review compared and ranked psychosocial interventions for the treatment of PTSD in adult refugees and asylum seekers. METHODS: Randomised studies of psychosocial interventions for adult refugees and asylum seekers with PTSD were systematically identified. PTSD symptoms at postintervention was the primary outcome. Standardised mean differences (SMDs) and ORs were pooled using pairwise and NMA. Study quality was assessed with the Cochrane Risk of Bias (RoB) tool, and certainty of evidence was assessed through the Confidence in Network Meta-Analysis application. RESULTS: A total of 23 studies with 2308 participants were included. Sixteen studies were conducted in high-income countries, and seven in low-income or middle-income countries. Most studies were at low risk of bias according to the Cochrane RoB tool. NMA on PTSD symptoms showed that cognitive behavioural therapy (CBT) (SMD=-1.41; 95% CI -2.43 to -0.38) and eye movement desensitisation and reprocessing (EMDR) (SMD=-1.30; 95% CI -2.40 to -0.20) were significantly more effective than waitlist (WL). CBT was also associated with a higher decrease in PTSD symptoms than treatment as usual (TAU) (SMD -1.51; 95% CI -2.67 to -0.36). For all other interventions, the difference with WL and TAU was not significant. CBT and EMDR ranked best according to the mean surface under the cumulative ranking. Regarding acceptability, no intervention had less dropouts than inactive interventions. CONCLUSION: CBT and EMDR appeared to have the greatest effects in reducing PTSD symptoms in asylum seekers and refugees. This evidence should be considered in guidelines and implementation packages to facilitate dissemination and uptake in refugee settings.

Study quality and efficacy of psychological interventions for posttraumatic stress disorder: a meta-analysis of randomized controlled trials.

BACKGROUND: Research indicates that higher study quality may be associated with smaller treatment effects. Yet, knowledge about the association between study quality and treatment efficacy for posttraumatic stress disorder (PTSD) is limited. We aimed at evaluating the efficacy of psychological interventions for adult PTSD and the association between study quality and treatment effects. METHODS: We conducted a systematic search to identify randomized controlled trials (RCTs) that examined the efficacy of psychological interventions for chronic PTSD symptoms in adult samples with at least 70% of patients being diagnosed with PTSD by means of a structured interview. We assessed study quality using the following eight criteria from prior research: N ⩾ 50, all patients met criteria for PTSD, a treatment manual was used, therapists were trained, treatment integrity was checked, intent-to-treat analyses were applied, randomization was conducted by an independent party, and treatment outcome was conducted by blind assessors. RESULTS: The search resulted in 136 RCTs with 8978 patients. Active treatment conditions were largely effective in reducing PTSD symptoms at posttreatment and follow-up (Hedges' g = 1.09 and 0.81, respectively) when compared to passive control conditions. The comparison to active control conditions at posttreatment and follow-up resulted in medium effect sizes. A total of 14 trials met all study quality criteria and these trials produced large effect sizes when compared to passive control conditions at posttreatment and follow-up. CONCLUSIONS: Overall, study quality was not significantly associated with effect size. The findings indicate that psychological interventions can effectively reduce PTSD symptoms irrespective of study quality.

Potential impact of physical distancing on physical and mental health: a rapid narrative umbrella review of meta-analyses on the link between social connection and health.

BACKGROUND: The imperative for physical distancing (mostly referred to as social distancing) during COVID-19 pandemic may deteriorate physical and mental health. We aimed at summarising the strength of evidence in the published literature on the association of physical and mental health with social connection via social isolation, living alone and loneliness. METHODS: We conducted a systematic search in April 2020 to identify meta-analyses using the Medline, PsycINFO and Web of Science databases. The search strategy included terms of social isolation, loneliness, living alone and meta-analysis. Eligible meta-analyses needed to report any sort of association between an indicator of social connection and any physical or mental health outcome. The findings were summarised in a narrative synthesis. RESULTS: Twenty-five meta-analyses met our criteria, of which 10 focused on physical health and 15 on mental health outcomes. The results suggest that lack of social connection is associated with chronic physical symptoms, frailty, coronary heart disease, malnutrition, hospital readmission, reduced vaccine uptake, early mortality, depression, social anxiety, psychosis, cognitive impairment in later life and suicidal ideation. CONCLUSIONS: The existing evidence clearly indicates that social connection is associated with a range of poor physical and mental health outcomes. A potential negative impact on these outcomes needs to be considered in future decisions on physical distancing measures.

Psychological interventions for posttraumatic stress disorder and depression in refugees: A meta-analysis of randomized controlled trials.

Millions of refugees around the globe suffer from posttraumatic stress disorder (PTSD) and/or depression. We conducted a meta-analysis of randomized controlled trials (RCTs) to determine the efficacy of psychological interventions for PTSD and/or depression in refugees. The meta-analysis was registered on the PROSPERO database (CRD42017071384). A search using the Medline, PsycINFO, and PILOTS databases was conducted in January 2019, resulting in 17 RCTs, of which 14 were conducted with adult refugees (1,108 participants) and 3 with young refugees (<18 years; 151 participants). Further inclusion criteria were at least 10 participants completing an active psychological intervention for PTSD, depression, or both and less than 50% of participants receiving concurrent psychotropic drugs. Random effects models showed that active interventions for adult PTSD yielded a medium to large aggregated effect size (g = 0.77; 95% confidence interval [CI] [0.26, 1.28]) at posttreatment when compared with passive and active control conditions. Active interventions for adult depression also produced large controlled effect sizes at posttreatment (g = 0.82; 95% CI [0.24, 1.40]). The effects appeared to persist over the average follow-up period of 6 months. The findings suggest that psychological interventions can effectively reduce symptoms of both PTSD and depression in adult refugees. However, the considerable heterogeneity between studies indicates that the efficacy may vary significantly. Future studies should aim to explore the substantial heterogeneity in effect sizes between studies with adult refugees. Additionally, more trials with young refugees suffering from PTSD or depression are needed to determine treatment efficacy for this population.

Effects of rule uncertainty on cognitive flexibility in a card-sorting paradigm.

Cognitive flexibility has been studied in two separate research traditions. Neuropsychologists typically rely on rather complex assessment tools such as the Wisconsin Card Sorting Test (WCST). In contrast, task-switching paradigms are used in experimental psychology to obtain more specific measures of cognitive flexibility. We aim to contribute to the integration of these research traditions by examining the role of the key factor that differs between the WCST and experimental task-switching paradigms: rule uncertainty. In two experimental studies, we manipulated the degree of rule uncertainty after rule switches in a computerized version of the WCST. Across a variety of task parameters, reducing rule uncertainty consistently impaired the speed and accuracy of responses when the rule designated to be more likely turned out to be incorrect. Other performance measures such as the number of perseverative errors were not significantly affected by rule uncertainty. We conclude that a fine-grained analysis of WCST performance can dissociate behavioural indicators that are affected vs. unaffected by rule uncertainty. By this means, it is possible to integrate WCST results and findings obtained from task-switching paradigms that do not involve rule uncertainty.