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

A large number of randomized controlled trials (RCTs) on psychological interventions for adult posttraumatic stress disorder (PTSD) have been published. We aimed at providing a comprehensive quantitative summary covering short and long-term efficacy, acceptability and trial quality. We conducted systematic searches in bibliographical databases to identify RCTs examining the efficacy (standardized mean differences in PTSD severity, SMDs) and acceptability (relative risk of all-cause dropout, RR) of trauma-focused cognitive behaviour therapy (TF-CBT), Eye Movement Desensitization and Reprocessing (EMDR), other trauma-focused psychological interventions (other-TF-PIs) and non-trauma-focused psychological interventions (non-TF-PIs) compared to each other or to passive or active control conditions. Hundred-fifty-seven RCTs met inclusion criteria comprising 11,565, 4,830 and 3,338 patients at post-treatment assessment, ≤ 5 months follow-up and > 5 months follow-up, respectively. TF-CBT was by fore the most frequently examined intervention. We performed random effects network meta-analyses (efficacy) and pairwise meta-analyses (acceptability). All therapies produced large effects compared to passive control conditions (SMDs ≥ 0.80) at post-treatment. Compared to active control conditions, TF-CBT and EMDR yielded medium treatment effects (SMDs ≥ 0.50 < 0.80), and other-TF-PIs and non-TF-PIs yielded small treatment effects (SMDs ≥ 0.20 < 0.50). Interventions did not differ in their short-term efficacy, yet TF-CBT was more effective than non-TF-PIs (SMD = 0.17) and other-TF-PIs (SMD = 0.30). Results remained robust in sensitivity and outlier-adjusted analyses. Similar results were found for long-term efficacy. Interventions also did not differ in terms of their acceptability, except for TF-CBT being associated with a slightly increased risk of dropout compared to non-TF-PIs (RR=1.36; 95% CI: 1.08-1.70). In sum, interventions with and without trauma focus appear effective and acceptable in the treatment of adult PTSD. TF-CBT is by far the most well-researched intervention and yields the highest efficacy. However, TF-CBT appears somewhat less acceptable than non-TF-PIs. ### Competing Interest Statement JM receives studentship funding from the Biotechnology and Biological Sciences Research Council (BBSRC, ref: 2050702) and Eli Lilly and Company Limited. ### Funding Statement This research received no specific grant from any funding agency, commercial or not-for-profit sectors. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: All data analysed were extracted from published journal articles. Except one unpublished trial with open access data available at: I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data analysed are publically accessible. No new data were created. The datasets and the R scripts are available on request via e-mail to the first/corresponding author (THH).