Evidence Synthesis Hub

Many patients drop out of guideline-recommended treatments for posttraumatic stress disorder (PTSD), yet there has been little systematic investigation of this issue. We aimed to examine dropout proportions from randomized controlled trials (RCTs) of guideline-recommended treatments for PTSD and whether proportions differed by type of treatment or trauma, PTSD severity or chronicity, or medication being permitted. Methods were systematic review and meta-analysis of RCTs of guideline-recommended treatments for PTSD.

Eighty-five trials, with data for 6804 participants were included in the meta-analyses. The mean dropout proportion for guideline-recommended treatment was 20.9% (95%CI 17.2, 24.9) with evidence of high heterogeneity across studies. Military trauma was associated with higher dropout than civilian trauma. The civilian trauma group had similar dropout rates from guideline-recommended treatments, and active, waitlist or treatment as usual controls. In the military trauma group, dropout was higher from guideline-recommended treatments compared to active, waitlist or treatment as usual controls.

Within this group, dropout from trauma-focused treatment was significantly higher than from non-trauma focused treatments overall, with the greatest difference in dropout rates occurring between randomization and treatment initiation. Most RCTs exclude participants who have comorbid substance use disorder, suicidal behaviour, or history of psychosis, which limits the generalizability of findings. Dropout from guideline-recommended treatment for PTSD is higher in populations who have experienced military trauma and this population dropout from treatment in higher proportions when it is trauma-focused. The reasons for disparate rates of dropouts from recommended PTSD treatments require further investigation.

There is currently no uniform definition of treatment response for posttraumatic stress disorder (PTSD) to guide researchers and clinicians in the area of posttraumatic mental health. The aim of this systematic review was to explore the operationalization of PTSD treatment response, by reviewing and synthesizing the key criteria used to define treatment response and treatment nonresponse in published trials. Randomized controlled trials (RCTs) assessing the effectiveness of first‐line interventions for PTSD were identified for inclusion.

Of those, 143 trials provided 226 definitions of treatment response, grouped under five main categories: treatment response (n = 181), remission (n = 23), recovery (n = 5), treatment nonresponse (n = 5), and worsening (n = 12). Overall, the results showed the PTSD field utilizes diverse and interchangeable operational definitions of treatment response and nonresponse, indicating a need for more precise conceptual definitions and operational criteria. A set of operational research definitions are presented in order to advance the PTSD treatment field.

The aim of this systematic review was to examine the efficacy of MDMA, ketamine, LSD, and psilocybin for the treatment of posttraumatic stress disorder (PTSD). A search of four databases for English language, peer-reviewed literature published from inception to 18th October 2019 yielded 2,959 records, 34 of which were screened on full-text. Observational studies and RCTs which tested the efficacy of MDMA, ketamine, LSD, or psilocybin for reducing PTSD symptoms in adults, and reported changes to PTSD diagnosis or symptomatology, were included.

Nine trials (five ketamine and four MDMA) met inclusion criteria. Trials were rated on a quality and bias checklist and GRADE was used to rank the evidence. The evidence for ketamine as a stand-alone treatment for comorbid PTSD and depression was ranked “very low”, and the evidence for ketamine in combination with psychotherapy as a PTSD treatment was ranked “low”. The evidence for MDMA in combination with psychotherapy as a PTSD treatment was ranked “moderate”.

This systematic review examined the efficacy of all augmentation approaches for first‐line posttraumatic stress disorder (PTSD) interventions. From 9,890 records, 34 trials were eligible for inclusion, covering 28 different augmentation approaches. Overall, augmentation approaches were ineffective if they targeted a mechanism similar to the first‐line treatment. Augmentation approaches combining two guideline‐recommended treatments were largely ineffective, reflecting ceiling effects.

Pharmacological augmentation approaches targeting fear extinction mechanisms were largely ineffective, or worsened outcomes relative to prolonged exposure alone, as these approaches may inadvertently strengthen fear memories. Augmentation approaches targeting general cognitive enhancement showed promise and provided support for augmentation interventions that require little cognitive or emotional work and target mechanisms different than the first‐line treatment.

Telepsychology holds promise as a treatment delivery method that may increase access to services as well as reduce barriers to treatment accessibility. The aim of this rapid evidence assessment was to assess the evidence for synchronous telepsychology interventions for 4 common mental health conditions (depression, anxiety, posttraumatic stress disorder, and adjustment disorder). Randomized controlled trials published between 2005 and 2016 that investigated synchronous telepsychology (i.e., telephone delivered, video teleconference delivered, or Internet delivered text based) were identified through literature searches. From an initial yield of 2,266 studies, 24 were included in the review.

Ten studies investigated the effectiveness of telephone-delivered interventions, 11 investigated the effectiveness of video teleconference (VTC) interventions, 2 investigated Internet-delivered text-based interventions, and 2 were reviews of multiple telepsychology modalities. There was sufficient evidence to support VTC and telephone-delivered interventions for mental health conditions. The evidence for synchronous Internet-delivered text-based interventions was ranked as “unknown.” Telephone-delivered and VTC-delivered psychological interventions provide a mode of treatment delivery that can potentially overcome barriers and increase access to psychological interventions.

Telepsychology holds promise as a treatment delivery method that may increase access to services as well as reduce barriers to treatment accessibility. The aim of this rapid evidence assessment was to assess the evidence for synchronous telepsychology interventions for 4 common mental health conditions (depression, anxiety, posttraumatic stress disorder, and adjustment disorder). Randomized controlled trials published between 2005 and 2016 that investigated synchronous telepsychology (i.e., telephone delivered, video teleconference delivered, or Internet delivered text based) were identified through literature searches.

From an initial yield of 2,266 studies, 24 were included in the review. Ten studies investigated the effectiveness of telephone-delivered interventions, 11 investigated the effectiveness of video teleconference (VTC) interventions, 2 investigated Internet-delivered text-based interventions, and 2 were reviews of multiple telepsychology modalities. There was sufficient evidence to support VTC and telephone-delivered interventions for mental health conditions. The evidence for synchronous Internet-delivered text-based interventions was ranked as “unknown.” Telephone-delivered and VTC-delivered psychological interventions provide a mode of treatment delivery that can potentially overcome barriers and increase access to psychological interventions.

Recent research has found that exposure to traumatic events may occur in certain patterns, rather than randomly. Person-centered analyses, and specifically latent class analysis, is becoming increasingly popular in examining patterns, or ‘classes’ of trauma exposure. This review aimed to identify whether there are consistent homogeneous subgroups of trauma-exposed individuals, and the relationship between these trauma classes and psychiatric diagnosis. A systematic review of the literature was completed using the databases EMBASE, MEDLINE (PubMed) and PsycINFO. From an initial yield of 189, 17 studies met inclusion criteria.

All studies identified a group of individuals who had a higher likelihood of exposure to a wide range of traumas types, and this group consistently exhibited worse psychiatric outcomes than other groups. Studies differed in the nature of the other groups identified although there was often a class with high levels of sexual interpersonal trauma exposure, and a class with high levels of non-sexual interpersonal trauma. There was some evidence that risk for psychiatric disorder differed across these classes. Person-centered approaches to understanding the relationship between trauma exposure and mental health may offer ways to improve our understanding of the role trauma exposure plays in increasing vulnerability to psychiatric disorder.