Anxiety, distress tolerance, and the relationship between complex posttraumatic stress disorder symptoms and alcohol use in veterans.

OBJECTIVES: Little is known about whether distress tolerance and anxiety mediate the relationship between comorbid complex posttraumatic stress disorder (CPTSD) and alcohol use among military veterans. Here, we investigated the contribution of distress tolerance and anxiety on the strength of the CPTSD and alcohol use association. We hypothesized that the impact of a two-factor model of CPTSD derived from subscale scores on the International Trauma Questionnaire (ITQ)-namely ITQ PTSD and ITQ Disturbances in Self Organization (DSO; e.g., issues with affective regulation/self-belief and shame)-on alcohol use severity would be mediated by anxiety but not by distress tolerance. METHODS: Participants included 403 community-dwelling United Kingdom (UK) veterans (91.64% male, Mage = 51.15 years, SD = 12.48) recruited as part of a larger, online study. RESULTS: Findings indicated that the influence of CPTSD symptoms on alcohol use severity was mediated by anxiety, not by distress tolerance, with greater relative impact due to ITQ DSO status than ITQ PTSD status. CONCLUSIONS: We identified the mediational influence of anxiety and distress tolerance on the association between CPTSD subscales and alcohol use in UK veterans. Interventions for anxiety may be adapted for reducing problematic alcohol use and the impact of CPTSD symptoms in veterans with comorbid PTSD and alcohol use disorder.

Social support as a predictor of outcomes of cognitive behavioral therapy with a trauma focus delivered face-to-face and via guided internet-based self-help.

There is mounting evidence that cognitive behavioral therapy with a trauma focus (CBT-TF) delivered via guided internet-based self-help is noninferior to CBT-TF delivered face-to-face for individuals with posttraumatic stress disorder (PTSD) of mild-to-moderate severity. The availability of multiple evidence-based treatment options creates a need to determine predictors of outcome to enable clinicians to make informed treatment recommendations. We examined perceived social support as a predictor of treatment adherence and response among 196 adults with PTSD enrolled in a multicenter pragmatic randomized controlled noninferiority trial. Perceived social support was measured using the Multidimensional Scale of Perceived Social Support and PTSD was assessed using the Clinician-Administered PTSD Scale for DSM-5. Linear regression was used to explore the associations between different dimensions of perceived social support (i.e., from friends, family, and significant others) and posttraumatic stress symptoms (PTSS) at baseline. Linear and logistic regression were used to determine whether these dimensions of support predicted treatment adherence or response for either treatment modality. Lower baseline perceived social support from family was associated with higher levels of PTSS, B = -0.24, 95% CI [-0.39, -0.08], p = .003, but the same did not apply to social support from friends or significant others. We did not find evidence that any dimension of social support predicted treatment adherence or response for either treatment. This work does not indicate that social support is a factor that can help predict the suitability of psychological therapy for PTSD delivered via guided internet-based self-help versus face-to-face.

Multiple session early psychological interventions for the prevention of post-traumatic stress disorder.

BACKGROUND: The prevention of long-term psychological distress following traumatic events is a major concern. Systematic reviews have suggested that individual psychological debriefing is not an effective intervention at preventing post-traumatic stress disorder (PTSD). Over the past 20 years, other forms of intervention have been developed with the aim of preventing PTSD. OBJECTIVES: To examine the efficacy of psychological interventions aimed at preventing PTSD in individuals exposed to a traumatic event but not identified as experiencing any specific psychological difficulties, in comparison with control conditions (e.g. usual care, waiting list and no treatment) and other psychological interventions. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO and ProQuest's Published International Literature On Traumatic Stress (PILOTS) database to 3 March 2018. An earlier search of CENTRAL and the Ovid databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to May 2016). We handsearched reference lists of relevant guidelines, systematic reviews and included study reports. Identified studies were shared with key experts in the field.We conducted an update search (15 March 2019) and placed any new trials in the 'awaiting classification' section. These will be incorporated into the next version of this review, as appropriate. SELECTION CRITERIA: We searched for randomised controlled trials of any multiple session (two or more sessions) early psychological intervention or treatment designed to prevent symptoms of PTSD. We excluded single session individual/group psychological interventions. Comparator interventions included waiting list/usual care and active control condition. We included studies of adults who experienced a traumatic event which met the criterion A1 according to the Diagnostic and Statistical Manual (DSM-IV) for PTSD. DATA COLLECTION AND ANALYSIS: We entered data into Review Manager 5 software. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data with a fixed-effect meta-analysis, except where there was heterogeneity, in which case we used a random-effects model. Two review authors independently assessed the included studies for risk of bias and discussed any conflicts with a third review author. MAIN RESULTS: This is an update of a previous review.We included 27 studies with 3963 participants. The meta-analysis included 21 studies of 2721 participants. Seventeen studies compared multiple session early psychological intervention versus treatment as usual and four studies compared a multiple session early psychological intervention with active control condition.Low-certainty evidence indicated that multiple session early psychological interventions may be more effective than usual care in reducing PTSD diagnosis at three to six months' follow-up (RR 0.62, 95% CI 0.41 to 0.93; I2 = 34%; studies = 5; participants = 758). However, there was no statistically significant difference post-treatment (RR 1.06, 95% CI 0.85 to 1.32; I2 = 0%; studies = 5; participants = 556; very low-certainty evidence) or at seven to 12 months (RR 0.94, 95% CI 0.20 to 4.49; studies = 1; participants = 132; very low-certainty evidence). Meta-analysis indicated that there was no statistical difference in dropouts compared with usual care (RR 1.34, 95% CI 0.91 to 1.95; I2 = 34%; studies = 11; participants = 1154; low-certainty evidence) .At the primary endpoint of three to six months, low-certainty evidence indicated no statistical difference between groups in reducing severity of PTSD (SMD -0.10, 95% CI -0.22 to 0.02; I2 = 34%; studies = 15; participants = 1921), depression (SMD -0.04, 95% CI -0.19 to 0.10; I2 = 6%; studies = 7; participants = 1009) or anxiety symptoms (SMD -0.05, 95% CI -0.19 to 0.10; I2 = 2%; studies = 6; participants = 945).No studies comparing an intervention and active control reported outcomes for PTSD diagnosis. Low-certainty evidence showed that interventions may be associated with a higher dropout rate than active control condition (RR 1.61, 95% CI 1.11 to 2.34; studies = 2; participants = 425). At three to six months, low-certainty evidence indicated no statistical difference between interventions in terms of severity of PTSD symptoms (SMD -0.02, 95% CI -0.31 to 0.26; I2 = 43%; studies = 4; participants = 465), depression (SMD 0.04, 95% CI -0.16 to 0.23; I2 = 0%; studies = 2; participants = 409), anxiety (SMD 0.00, 95% CI -0.19 to 0.19; I2 = 0%; studies = 2; participants = 414) or quality of life (MD -0.03, 95% CI -0.06 to 0.00; studies = 1; participants = 239).None of the included studies reported on adverse events or use of health-related resources. AUTHORS' CONCLUSIONS: While the review found some beneficial effects of multiple session early psychological interventions in the prevention of PTSD, the certainty of the evidence was low due to the high risk of bias in the included trials. The clear practice implication of this is that, at present, multiple session interventions aimed at everyone exposed to traumatic events cannot be recommended. There are a number of ongoing studies, demonstrating that this is a fast moving field of research. Future updates of this review will integrate the results of these new studies.

Pragmatic RAndomised controlled trial of a trauma-focused guided self-help Programme versus InDividual trauma-focused cognitive Behavioural therapy for post-traumatic stress disorder (RAPID): trial protocol.

BACKGROUND: There is good evidence that trauma-focused therapies for Post-Traumatic Stress Disorder are effective. However, they are not always feasible to deliver due a shortage of trained therapists and demands on the patient. An online trauma-focused Guided Self-Help (GSH) programme which could overcome these barriers has shown promise in a pilot study. This study will be the first to evaluate GSH against standard face-to-face therapy to assess its suitability for use in the NHS. METHODS: The study is a large-scale multi-centre pragmatic randomised controlled non-inferiority trial, with assessors masked to treatment allocation. One hundred and ninety-two participants will be randomly allocated to receive either face-to-face trauma-focused cognitive behaviour therapy (TFCBT) or trauma-focused online guided self-help (GSH). The primary outcome will be the severity of symptoms of PTSD over the previous week as measured by the Clinician Administered PTSD Scale for DSM5 (CAPS-5) at 16 weeks post-randomisation. Secondary outcome measures include PTSD symptoms over the previous month as measured by the CAPS-5 at 52 weeks plus the Impact of Event Scale - revised (IES-R), Work and Social Adjustment Scale (WSAS), Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder-7 (GAD-7), Alcohol Use Disorders Test (AUDIT-O), Multidimensional Scale for Perceived Social Support (MSPSS), short Post-Traumatic Cognitions Inventory (PTCI), Insomnia Severity Index (ISI) and General Self Efficacy Scale (GSES) measured at 16 and 52 weeks post-randomisation. Changes in health-related quality of life will be measured by the EQ-5D and the level of healthcare resource utilisation for health economic analysis will be determined by an amended version of the Client Socio-Demographic and Service Receipt Inventory European Version. The Client Satisfaction Questionnaire (CSQ) will be collected at 16 weeks post-randomisation to evaluate treatment satisfaction. DISCUSSION: This study will be the first to compare online GSH with usual face-to-face therapy for PTSD. The strengths are that it will test a rigorously developed intervention in a real world setting to inform NHS commissioning. The potential challenges of delivering such a pragmatic study may include participant recruitment, retention and adherence, therapist retention, and fidelity of intervention delivery. TRIAL REGISTRATION: ISRCTN13697710 registered on 20/12/2016.

The role of negative cognitions, emotion regulation strategies, and attachment style in complex post-traumatic stress disorder: Implications for new and existing therapies.

OBJECTIVE: We set out to investigate the association between negative trauma-related cognitions, emotional regulation strategies, and attachment style and complex post-traumatic stress disorder (CPTSD). As the evidence regarding the treatment of CPTSD is emerging, investigating psychological factors that are associated with CPTSD can inform the adaptation or the development of effective interventions for CPTSD. METHOD: A cross-sectional design was employed. Measures of CPTSD, negative trauma-related cognitions, emotion regulation strategies, and attachment style were completed by a British clinical sample of trauma-exposed patients (N = 171). Logistic regression analysis was used to assess the predictive utility of these psychological factors on diagnosis of CPTSD as compared to PTSD. RESULTS: It was found that the most important factor in the diagnosis of CPTSD was negative trauma-related cognitions about the self, followed by attachment anxiety, and expressive suppression. CONCLUSIONS: Targeting negative thoughts and attachment representations while promoting skills acquisition in emotional regulation hold promise in the treatment of CPTSD. Further research is required on the development of appropriate models to treat CPTSD that tackle skills deficit in these areas. PRACTITIONER POINTS: Results suggest that cognitive-behavioural interventions might be useful for the treatment of CPTSD. Targeting negative thoughts and attachment representations while promoting skills acquisition in emotional regulation hold promise in the treatment of CPTSD.

Internet-based guided self-help for posttraumatic stress disorder (PTSD): Randomized controlled trial.

BACKGROUND: There are numerous barriers that limit access to evidence-based treatment for posttraumatic stress disorder (PTSD). Internet-based guided self-help is a treatment option that may help widen access to effective intervention, but the approach has not been sufficiently explored for the treatment of PTSD. METHODS: Forty two adults with DSM-5 PTSD of mild to moderate severity were randomly allocated to internet-based self-help with up to 3 h of therapist assistance, or to a delayed treatment control group. The internet-based program included eight modules that focused on psychoeducation, grounding, relaxation, behavioural activation, real-life and imaginal exposure, cognitive therapy, and relapse prevention. The primary outcome measure was reduction in clinician-rated traumatic stress symptoms using the clinician administered PTSD scale for DSM-V (CAPS-5). Secondary outcomes were self-reported PTSD symptoms, depression, anxiety, alcohol use, perceived social support, and functional impairment. RESULTS: Posttreatment, the internet-based guided self-help group had significantly lower clinician assessed PTSD symptoms than the delayed treatment control group (between-group effect size Cohen's d = 1.86). The difference was maintained at 1-month follow-up and dissipated once both groups had received treatment. Similar patterns of difference between the two groups were found for depression, anxiety, and functional impairment. The average contact with treating clinicians was 2½ h. CONCLUSIONS: Internet-based trauma-focused guided self-help for PTSD is a promising treatment option that requires far less therapist time than current first line face-to-face psychological therapy.

Factors associated with the outcomes of a novel virtual reality therapy for military veterans with PTSD: Theory development using a mixed methods analysis.

BACKGROUND: Multi-modular motion-assisted memory desensitization and reconsolidation therapy (3MDR) is a new psychological intervention for people with post-traumatic stress disorder (PTSD). 3MDR is immersive, delivered in a virtual reality environment, and emphasises engagement, recollection and reprocessing. OBJECTIVE: Through a theory-driven examination of data relating to 10 out of 42 UK military veterans taking part in a trial of 3MDR, the principal objective was to explore the complex interrelationships between people, interventions and context and to investigate how factors within these domains interacted in specific outcome typologies. METHOD: Quantitative and qualitative data relating to 10 trial participants were derived from: researcher-assessed and self-report clinical measures; interviews; physiological recordings; words describing thoughts and feelings during therapy; and subjective unit of distress scores. Using a convergent mixed methods approach, data were tabulated using a person, intervention and context model. Participant summaries were grouped into outcome typologies, followed by an analysis of data convergence and divergence within each and an interpretation of identified patterns. RESULTS: Three outcome response typologies were identified: dramatic improvement, moderate improvement and minimal improvement. Within the person domain, factors associated with outcomes included walking capacity, commitment and ability to complete therapy, and levels of subjective distress. Within the intervention domain, factors associated with outcomes related to image selection and use, therapeutic alliance and orientations towards the tailoring of sessions. Within the context domain, factors associated with outcomes included reactions to the therapy environment. The patterning of secondary outcomes broadly corresponded with primary outcomes within each typology. Alongside patterned data differentiating aspects of the person, intervention and context domains, within the three response typologies data also existed where no obvious patterning was detected. CONCLUSIONS: The model developed here may have novel value in evaluating a range of personalised interventions, but further work is needed before confident assertions can be made of who is likely to benefit from 3MDR specifically.

The acceptability of a guided internet-based trauma-focused self-help programme (Spring) for post-traumatic stress disorder (PTSD).

Background: Guided internet-based, cognitive behavioural therapy with a trauma-focus (i-CBT-TF) is recommended in guidelines for post-traumatic stress disorder (PTSD). There is limited evidence regarding its acceptability, with significant dropout from individual face-to-face CBT-TF, suggesting non-acceptability at least in some cases.Objective: To determine the acceptability of a guided internet-based CBT-TF intervention, 'Spring', in comparison with face-to-face CBT-TF for mild to moderate PTSD.Method: Treatment adherence, satisfaction, and therapeutic alliance were measured quantitatively for participants receiving 'Spring' or face-to-face CBT-TF as part of a Randomised Controlled Trial. Qualitative interviews were conducted with a purposive sample of therapists and participants.Results: 'Spring' guided internet-based CBT-TF was found to be acceptable, with over 89% participants fully or partially completing the programme. Therapy adherence and alliance for 'Spring' and face-to-face CBT-TF did not differ significantly, apart from post-treatment participant-reported alliance, which was in favour of face-to-face CBT-TF. Treatment satisfaction was high for both treatments, in favour of face-to-face CBT-TF. Interviews with participants receiving, and therapists delivering 'Spring' corroborated its acceptability.Conclusions: Guided internet-based CBT-TF is acceptable for many people with mild to moderate PTSD. Findings provide insights into future implementation, highlighting the importance of personalising guided self-help, depending on an individual's presentation, and preferences.

Guided internet-based trauma-focused CBT is an acceptable treatment for PTSD.A model of acceptability explained 45% of variance in treatment outcome.Importance of adapting guided self-help to suit presentation and preferences.

Pragmatic randomised controlled trial of guided self-help versus individual cognitive behavioural therapy with a trauma focus for post-traumatic stress disorder (RAPID).

Background: Guided self-help has been shown to be effective for other mental conditions and, if effective for post-traumatic stress disorder, would offer a time-efficient and accessible treatment option, with the potential to reduce waiting times and costs. Objective: To determine if trauma-focused guided self-help is non-inferior to individual, face-to-face cognitive-behavioural therapy with a trauma focus for mild to moderate post-traumatic stress disorder to a single traumatic event. Design: Multicentre pragmatic randomised controlled non-inferiority trial with economic evaluation to determine cost-effectiveness and nested process evaluation to assess fidelity and adherence, dose and factors that influence outcome (including context, acceptability, facilitators and barriers, measured qualitatively). Participants were randomised in a 1 : 1 ratio. The primary analysis was intention to treat using multilevel analysis of covariance. Setting: Primary and secondary mental health settings across the United Kingdom's National Health Service. Participants: One hundred and ninety-six adults with a primary diagnosis of mild to moderate post-traumatic stress disorder were randomised with 82% retention at 16 weeks and 71% at 52 weeks. Nineteen participants and ten therapists were interviewed for the process evaluation. Interventions: Up to 12 face-to-face, manualised, individual cognitive-behavioural therapy with a trauma focus sessions, each lasting 60-90 minutes, or to guided self-help using Spring, an eight-step online guided self-help programme based on cognitive-behavioural therapy with a trauma focus, with up to five face-to-face meetings of up to 3 hours in total and four brief telephone calls or e-mail contacts between sessions. Main outcome measures: Primary outcome: the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, at 16 weeks post-randomisation. Secondary outcomes: included severity of post-traumatic stress disorder symptoms at 52 weeks, and functioning, symptoms of depression, symptoms of anxiety, alcohol use and perceived social support at both 16 and 52 weeks post-randomisation. Those assessing outcomes were blinded to group assignment. Results: Non-inferiority was demonstrated at the primary end point of 16 weeks on the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [mean difference 1.01 (one-sided 95% CI -∞ to 3.90, non-inferiority p = 0.012)]. Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, score improvements of over 60% in both groups were maintained at 52 weeks but the non-inferiority results were inconclusive in favour of cognitive-behavioural therapy with a trauma focus at this timepoint [mean difference 3.20 (one-sided 95% confidence interval -∞ to 6.00, non-inferiority p = 0.15)]. Guided self-help using Spring was not shown to be more cost-effective than face-to-face cognitive-behavioural therapy with a trauma focus although there was no significant difference in accruing quality-adjusted life-years, incremental quality-adjusted life-years -0.04 (95% confidence interval -0.10 to 0.01) and guided self-help using Spring was significantly cheaper to deliver [£277 (95% confidence interval £253 to £301) vs. £729 (95% CI £671 to £788)]. Guided self-help using Spring appeared to be acceptable and well tolerated by participants. No important adverse events or side effects were identified. Limitations: The results are not generalisable to people with post-traumatic stress disorder to more than one traumatic event. Conclusions: Guided self-help using Spring for mild to moderate post-traumatic stress disorder to a single traumatic event appears to be non-inferior to individual face-to-face cognitive-behavioural therapy with a trauma focus and the results suggest it should be considered a first-line treatment for people with this condition. Future work: Work is now needed to determine how best to effectively disseminate and implement guided self-help using Spring at scale. Trial registration: This trial is registered as ISRCTN13697710. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/192/97) and is published in full in Health Technology Assessment; Vol. 27, No. 26. See the NIHR Funding and Awards website for further award information.

Post-traumatic stress disorder is a common, disabling condition that can occur following major traumatic events. Typical symptoms include distressing reliving, avoidance of reminders and feeling a current sense of threat. First-choice treatments for post-traumatic stress disorder are individual, face-to-face talking treatments, of 12­16 hours duration, including cognitive behavioural therapy with a trauma focus. If equally effective treatments could be developed that take less time and can be largely undertaken in a flexible manner at home, this would improve accessibility, reduce waiting times and hence the burden of disease. RAPID was a randomised controlled trial using a web-based programme called Spring. The aim was to determine if trauma-focused guided self-help provided a faster and cheaper treatment for post-traumatic stress disorder than first-choice face-to-face therapy, while being equally effective. Guided self-help using Spring is delivered through eight steps. A therapist provides a 1-hour introductory meeting followed by four further, fortnightly sessions of 30 minutes each and four brief (around 5 minutes) telephone calls or e-mail contacts between sessions. At each session, the therapist reviews progress and guides the client through the programme, offering continued support, monitoring, motivation and problem-solving. One hundred and ninety-six people with post-traumatic stress disorder to a single traumatic event took part in the study. Guided self-help using Spring was found to be equally effective to first-choice face-to-face therapy at reducing post-traumatic stress disorder symptoms at 16 weeks. Very noticeable improvements were maintained at 52 weeks post-randomisation in both groups, when most results were inconclusive but in favour of face-to-face therapy. Guided self-help using Spring was significantly cheaper to deliver and appeared to be well-tolerated. It is noteworthy that not everyone benefitted from guided self-help using Spring, highlighting the importance of considering it on a person-by-person basis, and personalising interventions. But, the RAPID trial has demonstrated that guided self-help using Spring provides a low-intensity treatment option for people with post-traumatic stress disorder that is ready to be implemented in the National Health Service.

Guided, internet based, cognitive behavioural therapy for post-traumatic stress disorder: pragmatic, multicentre, randomised controlled non-inferiority trial (RAPID).

OBJECTIVE: To determine if guided internet based cognitive behavioural therapy with a trauma focus (CBT-TF) is non-inferior to individual face-to-face CBT-TF for mild to moderate post-traumatic stress disorder (PTSD) to one traumatic event. DESIGN: Pragmatic, multicentre, randomised controlled non-inferiority trial (RAPID). SETTING: Primary and secondary mental health settings across the UK's NHS. PARTICIPANTS: 196 adults with a primary diagnosis of mild to moderate PTSD were randomised in a 1:1 ratio to one of two interventions, with 82% retention at 16 weeks and 71% retention at 52 weeks. 19 participants and 10 therapists were purposively sampled and interviewed for evaluation of the process. INTERVENTIONS: Up to 12 face-to-face, manual based, individual CBT-TF sessions, each lasting 60-90 minutes; or guided internet based CBT-TF with an eight step online programme, with up to three hours of contact with a therapist and four brief telephone calls or email contacts between sessions. MAIN OUTCOME MEASURES: Primary outcome was the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) at 16 weeks after randomisation (diagnosis of PTSD based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, DSM-5). Secondary outcomes included severity of PTSD symptoms at 52 weeks, and functioning, symptoms of depression and anxiety, use of alcohol, and perceived social support at 16 and 52 weeks after randomisation. RESULTS: Non-inferiority was found at the primary endpoint of 16 weeks on the CAPS-5 (mean difference 1.01, one sided 95% confidence interval -∞ to 3.90, non-inferiority P=0.012). Improvements in CAPS-5 score of more than 60% in the two groups were maintained at 52 weeks, but the non-inferiority results were inconclusive in favour of face-to-face CBT-TF at this time point (3.20, -∞ to 6.00, P=0.15). Guided internet based CBT-TF was significantly (P<0.001) cheaper than face-to-face CBT-TF and seemed to be acceptable and well tolerated by participants. The main themes of the qualitative analysis were facilitators and barriers to engagement with guided internet based CBT-TF, treatment outcomes, and considerations for its future implementation. CONCLUSIONS: Guided internet based CBT-TF for mild to moderate PTSD to one traumatic event was non-inferior to individual face-to-face CBT-TF and should be considered a first line treatment for people with this condition. TRIAL REGISTRATION: ISRCTN13697710.

The course of mental health disorders after a disaster: predictors and comorbidity.

Current longitudinal disaster studies usually focus only on posttraumatic stress disorder (PTSD), although some studies have shown that increased risks for other disorders and comorbidity is common. To obtain an insight into the course of postdisaster psychopathology, a community sample of survivors of the Enschede fireworks disaster was followed from 2-3 weeks to 4-years postdisaster. Diagnostic interviews (Composite International Diagnostic Interview [CIDI]; World Health Organization, 1997) and childhood stressor interviews were administered at 2-years postdisaster (n = 260); the CIDI was repeated at 4-years postdisaster (n = 201, response rate 77.3%). At 2-years postdisaster many survivors (40.6%) suffered from PTSD (21.8%), specific phobia (21.5%), and/or depression (16.1%). These disorders were highly comorbid. At 4-years postdisaster, prevalence significantly diminished. Instead of full recovery, diagnostic classifications shifted in several survivors over time. This resulted in low rates of PTSD but still elevated rates of depression and specific phobia. The course of the 3 entangled disorders of PTSD, depression, and specific phobia was further studied by constructing 4 groups of survivors based on the diagnostic status at 2- and 4-years postdisaster: healthy, recovered, chronic, and delayed-onset. Initial depressive symptoms, maternal dysfunction, childhood physical abuse, and disaster exposure were found to discriminate between the groups and predict long-term psychopathology.

The psychophysiological response during post-traumatic stress disorder treatment with modular motion-assisted memory desensitisation and reconsolidation (3MDR).

Background: Psychophysiological changes are part of post-traumatic stress disorder (PTSD) symptomatology and can signal emotional engagement during psychological treatment. Objectives: The aim of this study was to explore psychophysiological responses during multi-modular motion-assisted memory desensitization and reconsolidation (3MDR) therapy. Increased self-reported distress, substantially increased heart rate (HR) and breathing rate (BR) were expected at the start of therapy and predicted to improve over time. Since physical exercise demands during therapy were low, any large HR or BR responses were considered part of the psychophysiological response. Methods: This study used pooled data collected during a randomized controlled trial of 3MDR, which demonstrated significant improvement as measured by the Clinician Administered PTSD Scale. Whilst attending therapy, HR and BR data, subjective units of distress (SUD) score and phrases to describe feelings whilst exposed to trauma-related images were collected continuously from 37 UK male military veterans with PTSD. Results: HR and BR were significantly increased throughout all sessions (p < .01 for both). Whilst HR was raised slightly remaining on average below 100 beats/minute, BR was increased substantially with average values between 40 and 50 breaths/minute. SUD scores were very high during therapy which concurred with the many negative feelings experienced during therapy sessions. Across the course of the treatment, SUD scores (p < .01) and negative feelings were reduced (p < .001), and positive feelings have increased (p < .01) significantly, reflecting improvements in clinicians assessed PTSD symptoms. Across therapy sessions, HR (p = .888) and BR (p = .466) responses did not change. Conclusions: The strong psychophysiological response alongside high levels of self-reported distress and negative feelings is interpreted as high emotional engagement during therapy. A novel finding was the very significant BR increase throughout recorded sessions. Future PTSD research should include BR response to therapy and explore breathing control as a treatment target.

Antecedentes: Los cambios psicofisiológicos son parte de la sintomatología del trastorno de estrés postraumático (TEPT) y pueden indicar un compromiso emocional durante el tratamiento psicológico.Objetivos: El objetivo de este estudio fue explorar las respuestas psicofisiológicas durante la terapia multimodular de desensibilización y reconsolidación de la memoria asistida por movimiento (3MDR). Se esperaba un aumento de la angustia autoinformada, un aumento sustancial de la frecuencia cardíaca (FC) y la frecuencia respiratoria (FR) al inicio de la terapia y se predijo que mejoraría con el tiempo. Dado que las demandas del ejercicio físico durante la terapia fueron bajas, cualquier respuesta grande de FC o FR se consideró parte de la respuesta psicofisiológica.Métodos: Este estudio utilizó datos agrupados recopilados durante un ensayo controlado aleatorio de 3MDR, que demostró una mejora significativa según lo medido por la Entrevista de TEPT Administrada por el Médico. Mientras asistían a la terapia, se recopilaron continuamente datos de FC y FR, puntuación de las unidades subjetivas de angustia (SUD en su sigla en inglés), y frases para describir los sentimientos mientras estaban expuestos a imágenes relacionadas con el trauma; de 37 veteranos militares masculinos del Reino Unido con TEPT.Resultados: FC y FR aumentaron significativamente a lo largo de todas las sesiones (p < .01 para ambas). Mientras que la FC se elevó ligeramente permaneciendo en promedio por debajo de 100 latidos por minuto, la FR aumentó sustancialmente con valores promedio entre 40 y 50 respiraciones por minuto. Los puntajes de SUD fueron muy altos durante la terapia, lo que coincidió con los muchos sentimientos negativos experimentados durante las sesiones de terapia. A lo largo del tratamiento, las puntuaciones SUD (p < .01) y los sentimientos negativos se redujeron (p < .001), y los sentimientos positivos aumentaron (p < .01) de manera significativa, lo que refleja mejoras en los síntomas de TEPT evaluados por el médico. A lo largo de las sesiones de terapia, las respuestas de FC (p = .888) y FR (p = .466) no cambiaron.Conclusiones: La fuerte respuesta psicofisiológica junto con los altos niveles de angustia autoinformada y sentimientos negativos se interpreta como un alto compromiso emocional durante la terapia. Un hallazgo novedoso fue el aumento muy significativo de FR durante las sesiones grabadas. La investigación futura del TEPT debería incluir la respuesta de la FR a la terapia y explorar el control de la respiración como un objetivo del tratamiento.

Psychometric properties of the PTSD Checklist for DSM-5 in a sample of trauma exposed mental health service users.

Background: PTSD self-report measures are frequently used in mental health services but very few have been evaluated in clinical samples that include civilians. The PCL-5 was developed to assess for DSM-5 PTSD. Objective: The aim of this study was to evaluate the psychometric properties of the PCL-5 in a sample of trauma-exposed mental health service users who were evidencing symptoms of PTSD. Method: Reliability and validity of the PCL-5 were investigated in a sample of 273 participants who reported past diagnosis for PTSD or who had screened positively for traumatic stress symptoms. Diagnostic utility was evaluated in comparison to the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Results: The PCL-5 demonstrated high internal consistency, good convergent and divergent validity, acceptable stability and good diagnostic utility. However, operating characteristics differed from those found in other samples. Scores of 43-44 provided optimal efficiency for diagnosing PTSD. A post hoc regression analysis showed that depression explained more of the variance in PCL-5 total score than the CAPS-5. Conclusion: Whilst the PCL-5 is psychometrically sound it appears to have difficulty differentiating self-reported depression and anxiety symptoms from PTSD in trauma-exposed mental health service users and clinicians should take care to assess full symptomatology when individuals screen positively on the PCL-5. Clinicians and researchers should also take care not to assume that operating characteristics of self-report PTSD measures are valid for mental health service users, when these have been established in other populations.

Antecedentes: Las mediciones auto reportadas para el trastorno de estrés postraumático (TEPT) se emplean con frecuencia en los servicios de salud mental pero muy pocas han sido evaluadas en muestras clínicas que incluyan a civiles. Se desarrolló la lista de chequeo de los síntomas del trastorno de estrés postraumático (PCL-5, por sus siglas en inglés) para la evaluación de los síntomas del TEPT según el DSM-5.Objetivo: El objetivo del estudio fue evaluar las propiedades psicométricas de la PCL-5 en una muestra de usuarios de servicios de salud mental expuestos a trauma y que mostraban síntomas del TEPT.Métodos: Se investigaron la confiabilidad y la validez de la PCL-5 en una muestra de 273 participantes que reportaron un diagnóstico previo de TEPT o que fueron tamizados como positivos para síntomas de estrés traumático. La utilidad diagnóstica se evaluó mediante la comparación con la escala para el TEPT administrada por un clínico según el DSM-5 (CAPS-5, por sus siglas en inglés).Resultados: La PCL-5 mostró alta consistencia interna, buena convergencia y validez divergente, estabilidad aceptable y buena utilidad diagnóstica. Sin embargo, las características operativas eran distintas de aquellas encontradas en otras muestras. Un puntaje entre 43 y 44 puntos tenía una eficiencia óptima para el diagnóstico del TEPT. Un análisis post hoc mostró que la depresión explicaba una mayor proporción de la varianza del puntaje total de la PCL-5 en comparación con la CAPS-5.Conclusión: Aunque la PCL-5 es psicométricamente sólida, impresiona presentar dificultad para discriminar los síntomas auto reportados de depresión y ansiedad con los síntomas del TEPT en usuarios expuestos a trauma en servicios de salud mental. En las personas que son tamizadas como positivas con la PCL-5, los clínicos deberían evaluar la totalidad los síntomas para el TEPT con atención. Los clínicos y los investigadores también deberían estar atentos a no asumir que las características operativas de las mediciones auto reportadas para el TEPT son válidas para usuarios de servicios de salud mental cuando estas han sido desarrolladas en otras poblaciones.

Internet-based psychological therapies: A qualitative study of National Health Service commissioners and managers views.

OBJECTIVES: To explore in-depth the views on Internet-based psychological therapies and their implementation from the perspective of National Health Service (NHS) commissioners and managers. DESIGN: Qualitative interview study. METHOD: Ten NHS commissioners and managers participated in a semi-structured, co-produced interview. Each transcribed interview was double-coded and thematically analysed using The Framework Method. RESULTS: Interviews generated three main themes. (1) Capacity issues across psychological therapy services create barriers to face-to-face therapies, and Internet-based interventions offer a solution. (2) Despite reservations, there is growing acceptance of Internet-based therapies. Different ways of connecting with patients are required, and Internet-based treatments are accessible and empowering treatment options, with guided self-help (GSH) preferred. Internet-based interventions may however exclude some individuals and be a threat to the therapeutic relationship between patient and practitioner. (3) Successful roll-out of Internet-based interventions would be facilitated by a strong empirical- or practice-based evidence, a national coordinated approach and timely training and supervision. Barriers to the roll-out include digital intervention set-up costs and delays due to NHS inflexibility. CONCLUSIONS: The study highlights factors influencing access to Internet-based therapies, important given the rapid evolution of e-therapies, and particularly timely given increasing use of remote therapies due to COVID-19 restrictions. Interviewees were open to Internet-based approaches, particularly GSH interventions, so long as they do not compromise on therapy quality. Interviewees acknowledged implementation may be challenging, and recommendations were offered. PRACTITIONER POINTS: There is a shift in practice and increasingly positive views from NHS staff around remote psychological therapies and different ways of connecting with patients, particularly since the COVID-19 pandemic. There is a strong preference for Internet-based psychological interventions that are guided and that include built-in outcome measures co-produced with service users. There is a need to raise awareness of the growing evidence base for Internet-based psychological therapies, including research examining therapeutic alliance across Internet-based and face-to-face therapies. Challenges implementing Internet-based psychological therapies include therapist resistance to changing working practices in general, and inflexibility of the NHS, and national, coordinated implementation efforts are encouraged.

The reconsolidation using rewind study (RETURN): trial protocol.

Background: An increasing body of research highlights reconsolidation-based therapies as emerging treatments for post-traumatic stress disorder (PTSD). The Rewind Technique is a non-pharmacological reconsolidation-based therapy with promising early results, which now requires evaluation through an RCT. Objectives: This is a preliminary efficacy RCT to determine if the Rewind Technique is likely to be a good candidate to test against usual care in a future pragmatic efficacy RCT. Methods: 40 participants will be randomised to receive either the Rewind Technique immediately, or after an 8 week wait. The primary outcome will be PTSD symptom severity as measured by the Clinician-Administered PTSD Scale for DSM5 (CAPS-5) at 8 and 16 weeks post-randomisation. Secondary outcome measures include the PTSD Checklist (PCL-5), International Trauma Questionnaire (ITQ), Patient Health Questionnaire (PHQ-9), the General Anxiety Disorder-7 (GAD-7), Insomnia Severity Index, the Euro-Qol-5D (EQ5D-5 L), the prominence of re-experiencing specific symptoms (CAPS-5) and an intervention acceptability questionnaire to measure tolerability of the intervention. Conclusions: This study will be the first RCT to assess the Rewind Technique. Using a cross-over methodology we hope to rigorously assess the efficacy and tolerability of Rewind using pragmatic inclusion criteria. Potential challenges include participant recruitment and retention. Trial registration: ISRCTN91345822.

Antecedentes: Un creciente cuerpo de investigación destaca las terapias basadas en la reconsolidación como tratamientos emergentes para el trastorno de estrés postraumático (TEPT). La Técnica de Rebobinado es una terapia no farmacológica basada en la reconsolidación con resultados tempranos prometedores, que ahora requiere evaluación a través de un ECA.Objetivos: Este es un ECA preliminar de eficacia para determinar si es probable que la técnica de rebobinado sea una candidata adecuada para probar en comparación con el cuidado habitual en un futuro ECA de eficacia pragmática.Método: 40 participantes serán asignados al azar para recibir la técnica de rebobinado inmediatamente o después de una espera de 8 semanas. El resultado primario será la gravedad de los síntomas del TEPT según lo medido por la Escala de TEPT administrada por el médico para DSM5 (CAPS-5 en su sigla en inglés) a las 8 y 16 semanas posteriores a la aleatorización. Las medidas de resultados secundarios incluyen la Lista de Verificación de TEPT (PCL-5 en su sigla en inglés), el Cuestionario Internacional de Trauma (ITQ en su sigla en inglés), el Cuestionario de Salud del Paciente (PHQ-9 en su sigla en inglés), el Trastorno de Ansiedad General-7 (GAD-7 en su sigla en inglés), el Índice de Gravedad del Insomnio, el Euro-Qol- 5D (EQ5D-5L en su sigla en inglés), la prominencia de re-experimentar los síntomas específicos (CAPS-5) y un cuestionario de aceptabilidad de la intervención para medir la tolerabilidad de la intervención.Conclusiones: Este estudio será el primer ECA para evaluar la Técnica de Rebobinado. Utilizando una metodología cruzada, esperamos evaluar rigurosamente la eficacia y tolerabilidad del Rebobinado utilizando criterios de inclusión pragmáticos. Los desafíos potenciales incluyen el reclutamiento y la retención de los participantes.Registro de prueba: ISRCTN91345822.

Early psychological interventions to treat acute traumatic stress symptoms.

BACKGROUND: The amelioration of psychological distress following traumatic events is a major concern. Systematic reviews suggest that interventions targeted at all of those exposed to such events are not effective at preventing post traumatic stress disorder (PTSD). Recently other forms of intervention have been developed with the aim of treating acute traumatic stress problems. OBJECTIVES: To perform a systematic review of randomised controlled trials of all psychological treatments and interventions commenced within three months of a traumatic event aimed at treating acute traumatic stress reactions. The review followed the guidelines of the Cochrane Collaboration. SEARCH STRATEGY: Systematic searches were performed of of CCDAN Registers up to August 2008. Editions of key journals were searched by hand over a period of two years; personal communication was undertaken with key experts in the field; online discussion fora were searched. SELECTION CRITERIA: Randomised controlled trials of any psychological intervention or treatment designed to reduce acute traumatic stress symptoms, with the exception of single session interventions. DATA COLLECTION AND ANALYSIS: Data were entered and analysed for summary effects using Review Manager 5.0 software. Standardised mean differences were calculated for continuous variable outcome data. Relative risks were calculated for dichotomous outcome data. When statistical heterogeneity was present a random effects model was applied. MAIN RESULTS: Fifteen studies (two with long term follow-up studies) were identified examining a range of interventions.In terms of main findings, twelve studies evaluated brief trauma focused cognitive behavioural interventions (TF-CBT). TF-CBT was more effective than a waiting list intervention (6 studies, 471 participants; SMD -0.64, 95% CI -1.06, -0.23) and supportive counselling (4 studies, 198 participants; SMD -0.67, 95% CI -1.12, -0.23). Effects against supportive counselling were still present at 6 month follow-up (4 studies, 170 participants; SMD -0.64, 95% CI -1.02, -0.25). There was no evidence of the effectiveness of a structured writing intervention when compared against minimal intervention (2 studies, 149 participants; SMD -0.15, 95% CI -0.48, 0.17). AUTHORS' CONCLUSIONS: There was evidence that individual TF-CBT was effective for individuals with acute traumatic stress symptoms compared to both waiting list and supportive counselling interventions. The quality of trials included was variable and sample sizes were often small. There was considerable clinical heterogeneity in the included studies and unexplained statistical heterogeneity observed in some comparisons. This suggests the need for caution in interpreting the results of this review. Additional high quality trials with longer follow up periods are required to further test TF-CBT and other forms of psychological intervention.

Sleep disturbance in post-traumatic stress disorder (PTSD): a systematic review and meta-analysis of actigraphy studies.

BACKGROUND: Sleep disturbance has been described as a 'hallmark' symptom of posttraumatic stress disorder (PTSD). Although there are robust findings of self-reported sleep disturbance in PTSD, evidence of sleep disturbance measured using actigraphy is less certain. OBJECTIVE: To conduct a systematic review and meta-analysis to determine whether there are any significant differences between individuals with and without PTSD in actigraph-derived sleep measures. METHOD: Case-control studies comparing participants with current PTSD to those without PTSD were eligible for inclusion. Sleep parameters of interest were: (1) total sleep time; (2) sleep onset latency; (3) wake after sleep onset (WASO); and (4) sleep efficiency. Data were meta-analysed as standardised mean differences (SMDs) and potential sources of heterogeneity were explored through meta-regression. Six actigraphy studies with 405 participants were included. RESULTS: There was no evidence of a statistically significant difference between those with and without PTSD in total sleep time (SMD 0.09, 95%CI -0.23 to 0.42); WASO (SMD 0.18, 95%CI -0.06 to 0.43); sleep latency (SMD 0.32, 95%CI -0.04 to 0.69); or sleep efficiency (SMD -0.28, 95%CI -0.78 to 0.21). CONCLUSIONS: Further high-quality research is required to determine whether there is a true difference in sleep between those with and without PTSD.

Antecedentes: La perturbación del sueño se ha descrito como un síntoma 'distintivo' del trastorno de estrés postraumático (TEPT). Aunque existen hallazgos sólidos de trastornos del sueño en el TEPT a través de auto-reportes, la evidencia de éstos medidos con el uso de actigrafía es más incierta.Objetivo: Realizar una revisión sistemática y un metanálisis para determinar si hay diferencias significativas entre los individuos con y sin TEPT en medidas de sueño derivadas de la actigrafía.Método: Los estudios de casos y controles incluidos como elegibles fueron aquéllos que compararon participantes con TEPT en curso con aquellos participantes sin TEPT. Los parámetros de sueño de interés fueron: (1) tiempo total del sueño; (2) latencia del inicio del sueño; (3) vigilia después del inicio de sueño (wake after sleep onset, WASO, en su sigla en inglés); y (4) eficiencia del sueño. Los datos fueron meta-analizados como diferencias de medias estandarizadas (DME) y se exploraron las posibles fuentes de heterogeneidad mediante metarregresión. Se incluyeron seis estudios de actigrafía con 405 participantes.Resultados: No hubo evidencia de una diferencia estadísticamente significativa entre aquellos con y sin TEPT en el tiempo total del sueño (DME 0.09, IC 95%: −0,23 a 0,42); WASO (DME 0.18, IC 95% −0.06 a 0.43); latencia del sueño (SMD 0.32, IC 95% −0.04 a 0.69); o eficiencia del sueño (SMD −0.28, IC 95% −0.78 a 0.21).Conclusiones: Se requieren futuras investigaciones de alta calidad para determinar si existe una verdadera diferencia en el sueño entre aquéllos con y sin TEPT.

Multiple session early psychological interventions for the prevention of post-traumatic stress disorder.

BACKGROUND: The prevention of long-term psychological distress following traumatic events is a major concern. Systematic reviews have suggested that individual Psychological Debriefing is not an effective intervention at preventing post traumatic stress disorder (PTSD). Recently other forms of intervention have been developed with the aim of preventing PTSD. OBJECTIVES: To examine the efficacy of multiple session early psychological interventions commenced within three months of a traumatic event aimed at preventing PTSD. Single session individual/group psychological interventions were excluded. SEARCH STRATEGY: Computerised databases were searched systematically, the most recent search was conducted in August 2008. The Journal of Traumatic Stress and the Journal of Consulting and Clinical Psychology were handsearched for the last two years. Personal communication was undertaken with key experts in the field. SELECTION CRITERIA: Randomised controlled trials of any multiple session early psychological intervention or treatment (two or more sessions) designed to prevent symptoms of PTSD. DATA COLLECTION AND ANALYSIS: Data were entered using Review Manager software. The methodological quality of included studies was assessed individually by two review authors. Data were analysed for summary effects using Review Manager 4.2. Mean difference was used for meta-analysis of continuous outcomes and relative risk for dichotomous outcomes. MAIN RESULTS: Eleven studies with a total of 941 participants were found to have evaluated brief psychological interventions aimed at preventing PTSD in individuals exposed to a specific traumatic event, examining a heterogeneous range of interventions. Eight studies were entered into meta-analysis. There was no observable difference between treatment and control conditions on primary outcome measures for these interventions at initial outcome (k=5, n=479; RR 0.84; 95% CI 0.60 to 1.17). There was a trend for increased self-report of PTSD symptoms at 3 to 6 month follow-up in those who received an intervention (k=4, n=292; SMD 0.23; 95% CI 0.00 to 0.46). Two studies compared a memory structuring intervention against supportive listening. There was no evidence supporting the efficacy of this intervention. AUTHORS' CONCLUSIONS: The results suggest that no psychological intervention can be recommended for routine use following traumatic events and that multiple session interventions, like single session interventions, may have an adverse effect on some individuals. The clear practice implication of this is that, at present, multiple session interventions aimed at all individuals exposed to traumatic events should not be used. Further, better designed studies that explore new approaches to early intervention are now required.

Early psychological intervention following recent trauma: A systematic review and meta-analysis.

Background: Post-traumatic stress disorder (PTSD) is a common and debilitating disorder which has a significant impact on the lives of sufferers. A number of early psychological interventions have been developed to try to prevent chronic difficulties. Objective: The objective of this study was to establish the current evidence for the effectiveness of multiple session early psychological interventions aimed at preventing or treating traumatic stress symptoms beginning within three months of trauma exposure. Methods: Randomized controlled trials of early multiple session psychological interventions aimed at preventing or reducing traumatic stress symptoms of individuals exposed to a traumatic event, fulfiling trauma criteria for an ICD or DSM diagnosis of PTSD were identified through a search of the Cochrane Common Mental Disorders Group Clinical Trials Registers database, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO and PILOTS. Two authors independently extracted study details and data and completed risk of bias assessments. Analyses were undertaken using Review Manager software. Quality of findings were rated according to 'Grades of Recommendation, Assessment, Development, and Evaluation' (GRADE) and appraised for clinical importance. Results: Sixty-one studies evaluating a variety of interventions were identified. For individuals exposed to a trauma who were not pre-screened for traumatic stress symptoms there were no clinically important differences between any intervention and usual care. For individuals reporting traumatic stress symptoms we found clinically important evidence of benefits for trauma-focused cognitive-behavioural therapy (CBT-T), cognitive therapy without exposure and eye movement desensitization and reprocessing (EMDR). Differences were greatest for those diagnosed with acute stress disorder (ASD) and PTSD. Conclusions: There is evidence for the effectiveness of several early psychological interventions for individuals with traumatic stress symptoms following trauma exposure, especially for those meeting the diagnostic threshold for ASD or PTSD. Evidence is strongest for trauma-focused CBT.

Antecedentes: El Trastorno de Estrés Postraumático (TEPT) es un trastorno frecuente y debilitante que tiene un impacto significativo en las vidas de los que lo padecen. Se han desarrollado una serie de intervenciones psicológicas tempranas para tratar de prevenir dificultades crónicas.Objetivo: El objetivo de este estudio fue establecer la evidencia actual para la eficacia de intervenciones psicológicas tempranas con múltiples sesiones con el objetivo de prevenir o tratar síntomas de estrés traumático que comenzaron en los tres meses posteriores a la exposición al trauma.Métodos: Se realizó una búsqueda bibliográfica basada en la base de datos de Cochrane de Estudios Clínicos de Trastornos Mentales Frecuentes, en el registro de ensayos controlados de Cochrane, MEDLINE, Embase, PsycINFO y PILOTS, para identificar ensayos controlados randomizados de intervenciones psicológicas tempranas de múltiples sesiones que tenían el objetivo de prevenir o reducir síntomas de estrés traumático en individuos expuestos a un evento traumático, y que cumplían los criterios de TEPT según la CIE o el DSM. Dos autores independientes extrajeron los detalles e información del estudio y completaron una evaluación de riesgo de sesgo. Se llevaron a cabo análisis usando el software Review Manager. La calidad de los hallazgos fue puntuada según los 'Grados de Recomendación, Valoración, Desarrollo y Evaluación' (GRADE pos sus siglas en inglés) y evaluada por su importancia clínica.Resultados: Se identificaron sesenta y un estudios que evaluaban una variedad de intervenciones. Para aquellos individuos que estuvieron expuestos a un trauma que no tuvieron una pre-evaluación de síntomas de estrés traumático no hubo una diferencia clínica importante entre cualquier intervención y cuidado usual. Para los individuos que reportaron síntomas de estrés traumático encontramos evidencia clínicamente significativa de los beneficios de la terapia cognitiva focalizada en el trauma (CBT-T por sus siglas en inglés), terapia cognitiva sin exposición y desensibilización y reprocesamiento a través de movimientos oculares (EMDR por sus siglas en inglés). Las diferencias fueron mayores para aquellos diagnosticados con trastornos de estrés agudo (ASD por sus siglas en inglés) y TEPT.Conclusiones: Existe evidencia para la eficacia de varias intervenciones psicológicas tempranas para individuos con síntomas de estrés traumático posterior a la exposición a un trauma, especialmente para aquellos que cumplen con los criterios para un diagnóstico completo de ASD o TEPT. La evidencia es más fuerte para la CBT-T.

Active duty and ex-serving military personnel with post-traumatic stress disorder treated with psychological therapies: systematic review and meta-analysis.

Background: Post-traumatic stress disorder (PTSD) is a major cause of morbidity amongst active duty and ex-serving military personnel. In recent years increasing efforts have been made to develop more effective treatments. Objective: To determine which psychological therapies are efficacious in treating active duty and ex-serving military personnel with post-traumatic stress disorder (PTSD). Method: A systematic review was undertaken according to Cochrane Collaboration Guidelines. The primary outcome measure was reduction in PTSD symptoms and the secondary outcome dropout. Results: Twenty-four studies with 2386 participants were included. Evidence demonstrated that CBT with a trauma focus (CBT-TF) was associated with the largest evidence of effect when compared to waitlist/usual care in reducing PTSD symptoms post treatment (10 studies; n = 524; SMD -1.22, -1.78 to -0.66). Group CBT-TF was less effective when compared to individual CBT-TF at reducing PTSD symptoms post treatment (1 study; n = 268; SMD -0.35, -0.11 to -0.59). Eye Movement Desensitization and Reprocessing (EMDR) therapy was not effective when compared to waitlist/usual care at reducing PTSD symptoms post treatment (4 studies; n = 92; SMD -0.83, -1.75 to 0.10). There was evidence of greater dropout from CBT-TF therapies compared to waitlist and Present Centred Therapy. Conclusions: The evidence, albeit limited, supports individual CBT-TF as the first-line psychological treatment of PTSD in active duty and ex-serving personnel. There is evidence for Group CBT-TF, but this is not as strong as for individual CBT-TF. EMDR cannot be recommended as a first line therapy at present and urgently requires further evaluation. Lower effect sizes than for other populations with PTSD and high levels of drop-out suggest that CBT-TF in its current formats is not optimally acceptable and further research is required to develop and evaluate more effective treatments for PTSD and complex PTSD in active duty and ex-serving military personnel.

Antecedentes: el trastorno de estrés postraumático (TEPT) es una causa importante de morbilidad entre el personal militar activo y en retiro. En los últimos años se han realizado esfuerzos crecientes para desarrollar tratamientos más efectivos.Objetivo: determinar qué terapias psicológicas son eficaces en el tratamiento del personal militar en servicio activo y en retiro con trastorno de estrés postraumático (TEPT).Método: se realizó una revisión sistemática de acuerdo con las Pautas de la Colaboración Cochrane. La medida de resultado primaria fue la reducción de los síntomas de TEPT y la secundaria los abandonos al tratamiento.Resultados: se incluyeron 24 estudios con 2386 participantes. La evidencia demostró que la Terapia cognitivo conductual centrada en el trauma (TCC-CT) se asoció con la mayor evidencia de efecto en comparación con la lista de espera/atención habitual en la reducción de los síntomas de TEPT después del tratamiento (10 estudios; n = 524; DME -1.22, -1.78 a - 0,66). La TCC-CT grupal fue menos efectivo en comparación con el TCC-CT individual para reducir los síntomas de TEPT después del tratamiento (1 estudio; n = 268; SMD -0.35, -0.11 a -0.59). La terapia de desensibilización y reprocesamiento por movimiento ocular (EMDR) no fue efectiva en comparación con la lista de espera/atención habitual para reducir los síntomas de TEPT después del tratamiento (4 estudios; n = 92; SMD -0.83, -1.75 a 0.10). Hubo evidencia de un mayor abandono de las terapias TCC-CT en comparación con la lista de espera y la terapia centrada en el presente.Conclusiones: La evidencia, aunque limitada, respalda la TCC-CT individual como el tratamiento psicológico de primera línea del TEPT en el personal militar en servicio activo y en retiro. Existe evidencia de TCC-CT grupal, pero esta no es tan consistente como para TCC-CT individual. No se puede recomendar EMDR como terapia de primera línea en la actualidad y requiere urgentemente una evaluación adicional. Los tamaños de efecto más bajos que para otras poblaciones con TEPT y altos niveles de abandono sugieren que TCC-TC en sus formatos actuales no es óptimamente aceptable y se requiere más investigación para desarrollar y evaluar tratamientos más efectivos para TEPT y TEPT complejo en personal militar en servicio activo y en retiro.