Meta-Analysis of the Treatment of Posttraumatic Stress Disorder in Adults With Comorbid Severe Mental Illness.

Objective: To evaluate the efficacy of psychosocial treatments for posttraumatic stress disorder (PTSD) among individuals with a comorbid severe mental illness (SMI; ie, schizophrenia, bipolar disorder, major depressive disorder).Data Sources: PubMed, PsycINFO, CINAHL, and Cochrane Library were searched from January 1998 to March 2020 using keywords related to PTSD, treatment, and severe mental illness.Study Selection: All clinical trials for PTSD psychotherapy among individuals with SMI were included. From 38 potentially eligible studies, a total of 14 clinical trials across 684 individuals with comorbid SMI and PTSD were identified and included in the analysis.Data Extraction: Data on demographic, SMI diagnosis, symptom severity, sample attrition, and treatment protocol received were extracted. Effect size calculations and subsequent meta-analyses were conducted using the Meta-Analysis Package for R (metafor) version 2.1-0 in R (3.6.0).Results: PTSD treatments had a large effect on PTSD outcomes among individuals with SMI, with patients experiencing a standard deviation reduction in PTSD symptomatology pre- to post-treatment (g = -1.009, P < .001, k = 34). Prolonged exposure (g = -1.464; P < .001; SE = 0.276; k = 5), eye movement desensitization and reprocessing (g = -1.351; P < .001; SE = 0.276; k = 5), and brief treatment program (g = -1.009; P < .001; SE = 0.284; k = 5) had the largest effects on PTSD symptoms.Conclusions: Although underrepresented in the PTSD literature, PTSD psychotherapies are effective for individuals with SMI. Treatments with an exposure-based component may have greater efficacy in this clinical population.

Psychological interventions for ICD-11 complex PTSD symptoms: systematic review and meta-analysis.

BACKGROUND: The 11th revision to the WHO International Classification of Diseases (ICD-11) identified complex post-traumatic stress disorder (CPTSD) as a new condition. There is a pressing need to identify effective CPTSD interventions. METHODS: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of psychological interventions for post-traumatic stress disorder (PTSD), where participants were likely to have clinically significant baseline levels of one or more CPTSD symptom clusters (affect dysregulation, negative self-concept and/or disturbed relationships). We searched MEDLINE, PsycINFO, EMBASE and PILOTS databases (January 2018), and examined study and outcome quality. RESULTS: Fifty-one RCTs met inclusion criteria. Cognitive behavioural therapy (CBT), exposure alone (EA) and eye movement desensitisation and reprocessing (EMDR) were superior to usual care for PTSD symptoms, with effects ranging from g = -0.90 (CBT; k = 27, 95% CI -1.11 to -0.68; moderate quality) to g = -1.26 (EMDR; k = 4, 95% CI -2.01 to -0.51; low quality). CBT and EA each had moderate-large or large effects on negative self-concept, but only one trial of EMDR provided useable data. CBT, EA and EMDR each had moderate or moderate-large effects on disturbed relationships. Few RCTs reported affect dysregulation data. The benefits of all interventions were smaller when compared with non-specific interventions (e.g. befriending). Multivariate meta-regression suggested childhood-onset trauma was associated with a poorer outcome. CONCLUSIONS: The development of effective interventions for CPTSD can build upon the success of PTSD interventions. Further research should assess the benefits of flexibility in intervention selection, sequencing and delivery, based on clinical need and patient preferences.

Clinical, Empirical, and Theoretical Rationale for Selection of Accelerated Resolution Therapy for Treatment of Post-traumatic Stress Disorder in VA and DoD Facilities.

INTRODUCTION: Post-traumatic stress disorder (PTSD) is a chronic, disabling psychiatric disorder prevalent among U.S. service members and veterans. First-line treatments for PTSD endorsed in the 2017 Veterans Affairs (VA)/Department of Defense (DoD) Clinical Practice Guideline for PTSD emphasize individual, manualized trauma-focused psychotherapies that have a primary component of exposure and/or cognitive restructuring. These include prolonged exposure (PE) therapy, cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR), and others. Accelerated resolution therapy (ART) is an emerging trauma-focused therapy not specifically referenced in the guideline, but one that is consistent with the recommendations and is derived directly from EMDR. One randomized clinical trial and multiple observational studies have suggested that ART can be delivered in an average of just four treatment sessions. This commentary reviews the clinical, empirical, and theoretical rationale for use of ART as a potential first-line PTSD treatment modality in VA and DoD facilities. MATERIALS AND METHODS: The clinical protocol of ART is summarized into discrete procedural steps. The theoretical rationale as to how ART may help clients process traumatic memories and resolve symptoms of PTSD is also discussed, including how repeated sets of smooth pursuit horizontal eye movements may facilitate a relaxation response and assist with processing emotionally intrusive memories. Herein, we review primary treatment results from four published studies of ART, including mean symptom score reductions on the 17-item PCL (PTSD checklist) after treatment with ART, along with effect sizes and percentage of treatment responders. Finally, the ART protocol is compared directly against specific recommended elements of trauma-focused therapy described in the VA/DoD Clinical Practice Guideline. RESULTS: The four published studies of ART reviewed (n = 291) included adult civilians and service members/veterans; the mean age was 42.3 ± 12.3 yr and 28.9% were female. Among 237 treatment completers (81.4% of the combined cohort), the mean number of ART sessions received was 3.9 ± 1.1. Across the four studies, mean treatment-related reductions in PCL scores ranged from 15.6 ± 13.2 to 25.6 ± 11.3, with a pooled mean reduction on the PCL of 20.6 ± 15.0. Effect sizes were large and ranged from 1.18 to 2.26 (p< 0.0005) across studies, with a pooled effect size of 1.38 (95% confidence interval: 1.20-1.56, p < 0.0001). Using the clinical cutpoint of >10-point reduction on the PCL instrument, clinically significant change (response) ranged from 63.8% to 100.0% across the four studies, with a pooled treatment response rate of 74.7%. Results were nominally attenuated when conservatively assuming no treatment response for non-completers. CONCLUSION: The ART protocol contains the core therapeutic elements and aligns closely with the current VA/DoD Clinical Practice Guideline. It has a plausible theoretical rationale and an evolving empirical research base that includes four studies with peer-reviewed publications, one of which was a randomized controlled trial. These features, along with the brevity of the treatment protocol, no requirement for narration, and high provider satisfaction rates, provide a rationale for the potential use of ART as a first-line PTSD treatment modality for active duty and veteran military personnel.

Treatment decision-making for posttraumatic stress disorder: The impact of patient and therapist characteristics.

OBJECTIVE: The purpose of this study was to assess how patient and provider factors influence the use of evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). METHOD: This study used a 2 × 2 survey design to assess providers' willingness to select EBPs for patients presented in clinical case vignettes. PTSD providers (N = 185) were randomized and asked to respond to 1 of 4 case vignettes in which the patients' age and alcohol use comorbidity were manipulated. RESULTS: Results suggested that the majority of providers were favorable toward EBPs, with 49% selecting cognitive processing therapy (CPT) as the first-line intervention, 25% selecting prolonged exposure (PE), and 8% selecting Eye Movement Desensitization Reprocessing therapy. Provider characteristics, but not patient characteristics, influenced treatment selection. Cognitive-behavioral therapy (CBT) orientation, younger age, fewer years of experience, and more time spent treating patients with PTSD were positively related to EBP selection. Provider training in specific EBPs (CPT or PE) increased the likelihood of recommending these treatments as first-line interventions. CONCLUSION: Taken together, these results suggest that providers are increasingly likely to view exposure-based EBPs for PTSD as effective, and that continued dissemination efforts to increase provider familiarity and comfort with these protocols will likely improve rates of EBP use across a variety of practice settings. (PsycINFO Database Record

Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis.

Numerous guidelines have been developed over the past decade regarding treatments for Posttraumatic stress disorder (PTSD). However, given differences in guideline recommendations, some uncertainty exists regarding the selection of effective PTSD therapies. The current manuscript assessed the efficacy, comparative effectiveness, and adverse effects of psychological treatments for adults with PTSD. We searched MEDLINE, Cochrane Library, PILOTS, Embase, CINAHL, PsycINFO, and the Web of Science. Two reviewers independently selected trials. Two reviewers assessed risk of bias and graded strength of evidence (SOE). We included 64 trials; patients generally had severe PTSD. Evidence supports efficacy of exposure therapy (high SOE) including the manualized version Prolonged Exposure (PE); cognitive therapy (CT), cognitive processing therapy (CPT), cognitive behavioral therapy (CBT)-mixed therapies (moderate SOE); eye movement desensitization and reprocessing (EMDR) and narrative exposure therapy (low-moderate SOE). Effect sizes for reducing PTSD symptoms were large (e.g., Cohen's d ~-1.0 or more compared with controls). Numbers needed to treat (NNTs) were <4 to achieve loss of PTSD diagnosis for exposure therapy, CPT, CT, CBT-mixed, and EMDR. Several psychological treatments are effective for adults with PTSD. Head-to-head evidence was insufficient to determine these treatments' comparative effectiveness, and data regarding adverse events was absent from most studies.

Dual imputation model for incomplete longitudinal data.

Missing values are a practical issue in the analysis of longitudinal data. Multiple imputation (MI) is a well-known likelihood-based method that has optimal properties in terms of efficiency and consistency if the imputation model is correctly specified. Doubly robust (DR) weighing-based methods protect against misspecification bias if one of the models, but not necessarily both, for the data or the mechanism leading to missing data is correct. We propose a new imputation method that captures the simplicity of MI and protection from the DR method. This method integrates MI and DR to protect against misspecification of the imputation model under a missing at random assumption. Our method avoids analytical complications of missing data particularly in multivariate settings, and is easy to implement in standard statistical packages. Moreover, the proposed method works very well with an intermittent pattern of missingness when other DR methods can not be used. Simulation experiments show that the proposed approach achieves improved performance when one of the models is correct. The method is applied to data from the fireworks disaster study, a randomized clinical trial comparing therapies in disaster-exposed children. We conclude that the new method increases the robustness of imputations.

Attentional bias in post-traumatic stress disorder diminishes after symptom amelioration.

BACKGROUND: Avoidance and hypervigilance to reminders of a traumatic event are among the main characteristics of post-traumatic stress disorder (PTSD). Attentional bias toward aversive cues in PTSD has been hypothesized as being part of the dysfunction causing etiology and maintenance of PTSD. The aim of the present study was to investigate the cognitive strategy underlying attentional bias in PTSD and whether normal cognitive processing is restored after a treatment suppressing core PTSD symptoms. METHODS: Nineteen healthy controls were matched for age, sex and education to 19 PTSD patients. We used the emotional stroop and detection of target tasks, before and after an average of 4.1 sessions of eye movement desensitization and reprocessing (EMDR) therapy. RESULTS: We found that on both tasks, patients were slower than controls in responding in the presence of emotionally negative words compared to neutral ones. After symptoms removal, patients no longer had attentional bias, and responded similarly to controls. CONCLUSION: These results support the existence of an attentional bias in PTSD patients due to a disengagement difficulty. There was also preliminary evidence that the disengagement was linked to PTSD symptomatology. It should be further explored whether attentional bias and PTSD involve common brain mechanisms.