Psychological and pharmacological treatments for adults with posttraumatic stress disorder

Abstract

OBJECTIVES:
To assess efficacy, comparative effectiveness, and harms of psychological and pharmacological treatments for adults with posttraumatic stress disorder (PTSD).

DATA SOURCES:
MEDLINE®, Cochrane Library, PILOTS, International Pharmaceutical Abstracts, CINAHL®, PsycINFO®, Web of Science, Embase, U.S. Food and Drug Administration Web site, and reference lists of published literature (January 1980–May 2012).

REVIEW METHODS:
Two investigators independently selected, extracted data from, and rated risk of bias of relevant trials. We conducted quantitative analyses using random-effects models to estimate pooled effects. To estimate medications’ comparative effectiveness, we conducted a network meta-analysis using Bayesian methods. We graded strength of evidence (SOE) based on established guidance.

RESULTS:
We included 92 trials of patients, generally with severe PTSD and mean age of 30s to 40s. High SOE supports efficacy of exposure therapy for improving PTSD symptoms (Cohen’s d −1.27; 95% confidence interval, −1.54 to −1.00); number needed to treat (NNT) to achieve loss of diagnosis was 2 (moderate SOE). Evidence also supports efficacy of cognitive processing therapy (CPT), cognitive therapy (CT), cognitive behavioral therapy (CBT)-mixed therapies, eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy for improving PTSD symptoms and/or achieving loss of diagnosis (moderate SOE). Effect sizes for reducing PTSD symptoms were large (e.g., 28.9- to 32.2-point reduction in Clinician-Administered PTSD Scale [CAPS]; Cohen’s d ~ −1.0 or more compared with controls); NNTs were ≤ 4 to achieve loss of diagnosis for CPT, CT, CBT-mixed, and EMDR. Evidence supports the efficacy of fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine for improving PTSD symptoms (moderate SOE); effect sizes were small or medium (e.g., 4.9- to 15.5-point reduction in CAPS compared with placebo). Evidence for paroxetine and venlafaxine also supports their efficacy for inducing remission (NNTs ~8; moderate SOE). Evidence supports paroxetine’s efficacy for improving depression symptoms and functional impairment (moderate SOE) and venlafaxine’s efficacy for improving depression symptoms, quality of life, and functional impairment (moderate SOE). Risperidone may help PTSD symptoms (low SOE). Network meta-analysis of 28 trials (4,817 subjects) found paroxetine and topiramate to be more effective than most medications for reducing PTSD symptoms, but analysis was based largely on indirect evidence and limited to one outcome measure (low SOE). We found insufficient head-to-head evidence comparing efficacious treatments; insufficient evidence to verify whether any treatment approaches were more effective for victims of particular trauma types or to determine comparative risks of adverse effects.

CONCLUSIONS:
Several psychological and pharmacological treatments have at least moderate SOE supporting their efficacy: exposure, CPT, CT, CBT-mixed therapies, EMDR, narrative exposure therapy, fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine.