early psychological intervention following recent trauma
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European Journal of Psychotraumatology
ISSN: 2000-8198 (Print) 2000-8066 (Online) Journal homepage: https://www.tandfonline.com/loi/zept20
Early psychological intervention following recenttrauma: A systematic review and meta-analysis
Neil P. Roberts, Neil J. Kitchiner, Justin Kenardy, Catrin E. Lewis & Jonathan I.Bisson
To cite this article: Neil P. Roberts, Neil J. Kitchiner, Justin Kenardy, Catrin E. Lewis &Jonathan I. Bisson (2019) Early psychological intervention following recent trauma: A systematicreview and meta-analysis, European Journal of Psychotraumatology, 10:1, 1695486, DOI:10.1080/20008198.2019.1695486
To link to this article: https://doi.org/10.1080/20008198.2019.1695486
© 2019 The Author(s). Published by InformaUK Limited, trading as Taylor & FrancisGroup.
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Early psychological intervention following recent trauma: A systematic reviewand meta-analysisNeil P. Roberts a,b, Neil J. Kitchiner b,c, Justin Kenardy d, Catrin E. Lewis b and Jonathan I. Bisson b
aPsychology & Psychological Therapies Directorate, Cardiff & Vale University Health Board, Cardiff, UK; bDivision of PsychologicalMedicine and Clinical Neurosciences, Cardiff University, Cardiff, UK; c, Veterans’ NHS Wales, Cardiff & Vale University Health Board,Cardiff, UK; dPsychology and Medicine, University of Queensland, Brisbane, Australia
ABSTRACTBackground: Post-traumatic stress disorder (PTSD) is a common and debilitating disorderwhich has a significant impact on the lives of sufferers. A number of early psychologicalinterventions have been developed to try to prevent chronic difficulties.Objective: The objective of this study was to establish the current evidence for the effec-tiveness of multiple session early psychological interventions aimed at preventing or treat-ing traumatic stress symptoms beginning within three months of trauma exposure.Methods: Randomized controlled trials of early multiple session psychological interventionsaimed at preventing or reducing traumatic stress symptoms of individuals exposed toa traumatic event, fulfiling trauma criteria for an ICD or DSM diagnosis of PTSD were identifiedthrough a search of the Cochrane Common Mental Disorders Group Clinical Trials Registersdatabase, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO andPILOTS. Two authors independently extracted study details and data and completed risk of biasassessments. Analyses were undertaken using Review Manager software. Quality of findingswere rated according to ‘Grades of Recommendation, Assessment, Development, andEvaluation’ (GRADE) and appraised for clinical importance.Results: Sixty-one studies evaluating a variety of interventions were identified. For indivi-duals exposed to a trauma who were not pre-screened for traumatic stress symptoms therewere no clinically important differences between any intervention and usual care. Forindividuals reporting traumatic stress symptoms we found clinically important evidence ofbenefits for trauma-focused cognitive-behavioural therapy (CBT-T), cognitive therapy with-out exposure and eye movement desensitization and reprocessing (EMDR). Differences weregreatest for those diagnosed with acute stress disorder (ASD) and PTSD.Conclusions: There is evidence for the effectiveness of several early psychological interven-tions for individuals with traumatic stress symptoms following trauma exposure, especiallyfor those meeting the diagnostic threshold for ASD or PTSD. Evidence is strongest fortrauma-focused CBT.
Intervención psicológica temprana tras un trauma reciente: unarevisión sistemática y meta-análisisAntecedentes: El Trastorno de Estrés Postraumático (TEPT) es un trastorno frecuentey debilitante que tiene un impacto significativo en las vidas de los que lo padecen. Sehan desarrollado una serie de intervenciones psicológicas tempranas para tratar de prevenirdificultades crónicas.Objetivo: El objetivo de este estudio fue establecer la evidencia actual para la eficacia deintervenciones psicológicas tempranas con múltiples sesiones con el objetivo de preveniro tratar síntomas de estrés traumático que comenzaron en los tres meses posteriores a laexposición al trauma.Métodos: Se realizó una búsqueda bibliográfica basada en la base de datos de Cochrane deEstudios Clínicos de Trastornos Mentales Frecuentes, en el registro de ensayos controlados deCochrane, MEDLINE, Embase, PsycINFO y PILOTS, para identificar ensayos controlados rando-mizados de intervenciones psicológicas tempranas de múltiples sesiones que tenían el objetivode prevenir o reducir síntomas de estrés traumático en individuos expuestos a un eventotraumático, y que cumplían los criterios de TEPT según la CIE o el DSM. Dos autores indepen-dientes extrajeron los detalles e información del estudio y completaron una evaluación deriesgo de sesgo. Se llevaron a cabo análisis usando el software Review Manager. La calidad delos hallazgos fue puntuada según los ‘Grados de Recomendación, Valoración, Desarrolloy 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 interven-ciones. 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 entrecualquier intervención y cuidado usual. Para los individuos que reportaron síntomas de estrés
ARTICLE HISTORYReceived 14 May 2019Revised 28 October 2019Accepted 29 October 2019
KEYWORDSPost-traumatic stressdisorder; psychologicalintervention; earlyintervention; prevention;systematic review; meta-analysis
PALABRAS CLAVETrastorno de estrespostraumático; intervencionpsicológica; intervencióntemprana; prevención;Revisión Sistemática; meta-análisis
关键词创伤后应激障碍; 心理干预; 早期干预; 预防; 系统综述; 元分析
HIGHLIGHTS• We found no clinicallyimportant evidence for thebenefit of early interventionoffered to all individualsexposed to a traumaticevent, regardless ofsymptomatology.• There was evidence ofa clinically important effectfor trauma-focused CBT(CBT-T), brief EMDR andcognitive therapy withoutexposure.• Evidence was strongest forCBT-T.
CONTACT Neil P. Roberts [email protected] Cardiff & Vale University Health Board, Cardiff University, Hadyn Ellis Building, MaindyRoad, Cardiff CF24 4HQ, UK
Supplemental data for this article can be accessed here.
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY2019, VOL. 10, 1695486https://doi.org/10.1080/20008198.2019.1695486
© 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/),which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
traumático encontramos evidencia clínicamente significativa de los beneficios de la terapiacognitiva focalizada en el trauma (CBT-T por sus siglas en inglés), terapia cognitiva sinexposición y desensibilización y reprocesamiento a través de movimientos oculares (EMDRpor sus siglas en inglés). Las diferencias fueron mayores para aquellos diagnosticados contrastornos de estrés agudo (ASD por sus siglas en inglés) y TEPT.Conclusiones: Existe evidencia para la eficacia de varias intervenciones psicológicas tem-pranas para individuos con síntomas de estrés traumático posterior a la exposición a untrauma, especialmente para aquellos que cumplen con los criterios para un diagnósticocompleto de ASD o TEPT. La evidencia es más fuerte para la CBT-T.
近期创伤后的早期心理干预：系统综述和元分析
背景：创伤后应激障碍（PTSD）是一种常见的, 使人衰弱的疾病，对患者的生活有重大影响。为预防发展为慢性疾病，已经开发出许多早期心理干预措施。
目标：本研究的目的是为旨在预防或治疗创伤暴露三个月内开始出现的创伤应激症状的多阶段早期心理干预的有效性建立现有证据。
方法：通过搜索Cochrane常见精神障碍小组临床试验注册数据库, Cochrane 临床对照试验数据库, MEDLINE, Embase, PsycINFO 和 PILOTS，确定了早期多阶段心理干预的随机对照试验。这些干预旨在预防或减轻遭受创伤事件且符合 ICD 或 DSM 诊断 PTSD 的创伤标准的个体的创伤应激症状。两位作者分别独自提取了研究细节和数据，并完成了误差风险评估。使用 Review Manager 软件进行分析。根据‘推荐分级的评估, 制定与评价’（GRADE）对结果的质量进行评级并评估其临床重要性。
结果：确定了评估多种干预措施的61项研究。对于有创伤暴露但未预先筛查创伤应激症状的个体，任何干预措施和日常护理间均无重要的临床差异。对于报告有创伤应激症状者，我们发现聚焦创伤的认知行为疗法（CBT-T）, 无暴露认知疗法以及眼动脱敏与再加工（EMDR）效益的重要临床证据。在被诊断为急性应激障碍（ASD）和 PTSD 的患者中差异最大。
结论：有证据表明了对于创伤暴露后患有创伤应激症状者，特别是那些达到 ASD 或 PTSD诊断阈值的个体，几种早期心理干预的有效性。对于聚焦创伤的 CBT 证据最充分。
1. Introduction
Numerous studies demonstrate that a range of traumaticexperiences can cause psychological difficulties to thoseexposed (Berger et al., 2012, Brunet, Monson, Liu, &Fikretoglu, 2015; Dworkin, Menon, Bystrynski, & Allen,2017; Lowe & Galea, 2017; Neria, Nandi, & Galea, 2008).For many, these difficulties are short lived or subclinical,and diminish over time without the need for medical orpsychological intervention (Giummarra, Lennox, Dali,Costa, & Gabbe, 2018; McNally, Bryant, & Ehlers,2003). However, psychological difficulties may developand persist for some of those exposed. These difficultiesinclude acute stress disorder (ASD) and post-traumaticstress disorder (PTSD). Around a third of individualswith PTSD at 4–6 weeks post trauma exposure remit by3 months (Santiago et al., 2013); whilst for aroundanother third of individuals symptoms become chronicand unremitting (Kessler, Sonnega, Bromet, Hughes, &Nelson, 1995; Santiago et al., 2013). Estimated life-timeprevalence rates of PTSD have been found to vary from1.3% to 8.8% (Atwoli, Stein, Koenen, & McLaughlin,2015). Rates of PTSD also vary according to traumatype, with an estimated mean conditional risk followingany trauma exposure of 4.0%, with much higher rates forsome types of interpersonal trauma (Kessler et al., 2017)which tend not to show the same pattern of symptomreduction (Santiago et al., 2013). PTSD symptoms canhave a considerable impact on the life trajectory of thoseexposed to trauma and their families (McFarlane, 2010;Shalev et al., 2019). Typically, symptoms affect social,
occupational and interpersonal functioning, and physicalhealth. PTSD is frequently associated with comorbidityand unhealthy coping mechanism, which can becomechronic and entrenched over time (Shalev et al., 2019).PTSD has a significant economic burden (Ferry et al.,2015; Greenberg et al., 1999).
As the effects of trauma exposure and the develop-ment of conditions such as PTSD have become betterunderstood, there have been increasing efforts todevelop psychological and pharmacological interven-tions that might prevent the onset of disorder or ame-liorate early symptoms (Kearns, Ressler, Zatzick, &Rothbaum, 2012; McNally et al., 2003). For a time,Psychological Debriefing (also known as CriticalIncident Stress Debriefing) was a widely used form ofearly intervention. However, its use has declined asevidence challenging its efficacy has emerged (Bastos,Furuta, Small, McKenzie-McHarg, & Bick, 2015; Rose,Bisson, Churchill, & Wessely, 2002). Over the past20 years or so, a range of other approaches, mainlybased on established cognitive behavioural therapy(CBT) for PTSD, have emerged (Kearns et al., 2012).More recently some groups have started to evaluatetelephone-based approaches and approaches based onnew technology in order to increase accessibility topotentially effective interventions.
In 2009 we published a systematic review and meta-analysis of randomized controlled trials (RCTs) of psy-chological interventions aimed at preventing or treatingPTSD within three months of a traumatic event
2 N. P. ROBERTS ET AL.
(Roberts, Kitchiner, Kenardy, & Bisson, 2009). Thisreview included 25 studies. We found no evidence tosupport the use of preventative interventions offered toindividuals irrespective of whether they were sympto-matic or not. However, we did find evidence to supportthe use of trauma focused cognitive behavioural therapy(CBT-T) in studies targeting individuals with earlytraumatic stress symptoms. Effects were strongest fortreatment of acute stress disorder and posttraumaticstress disorder. A subsequent review conducted by theUS Agency for Health Care Research and Quality(AHRQ) identified a smaller pool of 19 studies butreported similar findings (Forneris et al., 2013).A review focusing specifically on individuals who suf-fered traumatic injury which included 26mostly rando-mised controlled trials (RCTs) also found support forcognitive behavioural interventions, alongside small butsignificant effects for collaborative care basedapproaches (Giummarra et al., 2018). Neither of thesereviews made a distinction between preventative inter-ventions aimed at all individuals exposed and studiesfocusing specifically on individuals who were sympto-matic. Since our previous review (Roberts et al., 2009),a range of new early interventions have been developedand evaluated, including brief EMDR, new technologybased approaches and interventions aimed at those whohave experienced serious illnesses. In light of new devel-opments in the field, the purpose of this paper is toprovide an update of our previous review of all availableearly intervention studies aiming to prevent or treattraumatic stress symptoms following exposure to anevent fulfilling trauma criteria for an ICD or DSMdiagnosis of PTSD. The review was undertaken asa part of the process for the International Society forTraumatic Stress Studies (ISTSS) Treatment Guidelines(Bisson et al., 2019).
2. Method
2.1. Data sources
Following on from the previous search, we undertooka systematic computerized literature search of theCochrane Common Mental Disorders Group clinicaltrials registers databases for studies published fromJanuary 2008 to May 2016 using the search termsPTSD or posttrauma* or post-trauma* or ‘post trauma*’or ‘combat disorder*’ or ‘stress disorder*’. These data-bases are collated and updated on a weekly basis fromMEDLINE, EMBASE and PsycINFO. A further searchwas undertaken in March 2018. We chose not toexclude any potential study based on date of publica-tion, at any time point. Searches were undertaken aspart of a search process to support development of newPTSD treatment guidelines for the ISTSS (Bisson et al.,2019). See Appendix 1 (online supplement) for detailsof the search terms and parameters. We checked the
reference lists of studies identified in the search, relatedreview articles and management guidelines. We con-tacted authors of unpublished studies that had com-pleted recruitment when there was a registered protocolavailable on a trial register, such as Clinical Trials. Weposted a list of identified studies on the website of theInternational Society for Traumatic Stress website andasked the membership to identify studies that we mighthave missed.
2.2. Study selection
Study selection followed the procedure in our previousreview (Roberts et al., 2009). Study abstracts were readindependently by two of the reviewers to determine ifthey potentially met the inclusion criteria. The fullmanuscript of all studies that either reviewer felt poten-tially met the criteria were obtained and read indepen-dently by two reviewers. To be included, a study had tobe an RCT that considered one or more defined psy-chological intervention or treatment aimed at prevent-ing or reducing traumatic stress symptoms in adultsfollowing events that appeared to fulfill criteria fora traumatic event according to DSM or ICD PTSDdiagnostic descriptions (excluding single session pre-ventative interventions), in comparison witha placebo, other control (e.g. usual care or waiting listcontrol) or alternative psychological treatment condi-tion. All studies had to have been completed and ana-lysed by October 2018 with an available studymanuscript. Presence or absence of symptoms, samplesize, publication status and language of publicationwere not used to determine whether a study should beincluded. The review considered studies involvingadults aged 18 and over only. In cases where therewere a combination of adults and adolescents, at least80% of the sample had to be 18 or over.
2.3. Data extraction
A data extraction sheet was designed to capture datawhich was then entered into Review Management 5(RevMan-5.3) software (Review Manager [RevMan],2014). Information extracted included demographicdetails of participants, inclusion and exclusion criteria,details of the traumatic event, the randomization pro-cess, the interventions used, drop-out rates and out-come data. Study quality was assessed with theCochrane Collaboration’s tool for assessing risk ofbias (Higgins et al., 2011) using the domains: sequencegeneration, allocation concealment (selection bias),blinding of assessors (detection bias), incomplete out-come data (attrition bias), selective outcome reporting,and other sources of bias. Data were extracted andquality assessed by two reviewers independently. Anydisagreements were discussed with a third reviewerand a consensus achieved.
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 3
2.4. Data synthesis
In line with our previous review (Roberts et al., 2009)we separated trials into three separate groups:
(1) Studies that have offered intervention beginningwithin three months to any individual exposedto a traumatic event irrespective of their symp-toms with the aim of preventing PTSD.
(2) Interventions begun within three months withthe aim of preventing PTSD or ongoing distressin individuals with traumatic stress symptoms.
(3) Interventions begun within three months withthe aim of treating ASD or PTSD in indivi-duals who already met diagnosis.
In our previous review we combined data from allstudies evaluating interventions aimed at any indi-vidual exposed to a traumatic event irrespective oftheir symptoms in one meta-analysis (Roberts et al.,2009). In contrast, in this review we only combineddata from studies of similar interventions for all theabove groupings. We previously identified severalstudies evaluating CBT-T for individuals with trau-matic stress symptoms. We considered undertakingevaluation of CBT-T studies by specific interventionbut we took the view that there were insufficientstudies following a specific model to make thisapproach meaningful at this time. As previously,CBT-T was defined as any intervention that focusedon the trauma using written, imaginal or in-vivoexposure therapy with or without cognitive therapyand other cognitive behavioural techniques.
Our primary outcome was PTSD symptom sever-ity as this is the outcome most widely reported in thetraumatic stress literature (Bisson, Roberts, Andrew,Cooper, & Lewis, 2013). When an individual studyreported both a clinician-administered and a self-report measure, primacy was given to outcomesusing the clinician-administered measure. PTSDdiagnosis was our other outcome of interest. Weundertook analyses with follow-up data where thiswas available. Time points were decided a priori aspost-treatment, three to six months post-trauma,seven to 12 months post-trauma, one to two yearspost-trauma, and two years and beyond, based on ourknowledge of commonly used follow-up points usedin previous early intervention studies.
Data were analysed for summary effects using theReview Manager 5.3 program (RevMan, 2014). All con-tinuous outcomes were analysed using standard meandifferences (SMD), in order to compare effects acrossanalyses. SMD assumes that all scales are measuring thesameunderlying symptomor condition. Relative riskwascalculated for diagnostic status. 95% confidence intervalswere calculated for all outcomes. Available case analysisand intent to treat analysis with imputation using the lastobservation carried forward method were performedwhen enough information was available. In cases where
there was inadequate information within the paper toperform these analyses further informationwas requestedfrom the lead author.
Heterogeneity between studies was assessed by con-sidering the I2 and chi2 test of heterogeneity. Thisstatistic measures the percentage of variation that isnot due to chance (Fletcher, 2007). An I2 of less than30% was taken to indicate mild heterogeneity anda fixed effects model was used. When the I2 wasgreater or equal to 30% a random-effects model wasused. A visual inspection of the forest plots was used asa test of robustness of these findings. We decideda priori that if a minimum of 10 studies were availablein a meta-analysis, we would prepare funnel plots andexamine them for signs of asymmetry. Where asym-metry was indicated, we planned to consider otherpossible reasons for this. We assessed the quality ofevidence using the ‘Grades of Recommendation,Assessment, Development, and Evaluation’ (GRADE)approach (Guyatt, Oxman, Schünemann, Tugwell, &Knottnerus, 2011, Guyatt et al., 2013; Langendamet al., 2013) using five factors: limitations in studydesign and implementation of available studies, indir-ectness of evidence, unexplained heterogeneity orinconsistency of results, imprecision of effect esti-mates, and potential publication bias. The quality ofevidence for each comparison was graded according toour confidence that the estimate of effect wouldremain unchanged as a result of further research.A high rating indicates that further research is veryunlikely to change our confidence in the estimate ofeffect; a moderate rating indicates that research islikely to have an important impact on the confidencein the estimate of effect and may change the estimate;low quality indicates that further research is very likelyto have an important impact on confidence in theestimate of effect and is likely to change the estimate;very low quality indicates that the estimate of effect isvery uncertain. Finally, we rated findings in terms ofclinical importance. We used a definition of clinicalimportance, which was developed by the ISTSSTreatment Guidelines Committee and approved bythe ISTSS Board and membership (Bisson et al.,2019), building on previous work by the NationalInstitute of Health and Care Excellence (NationalCollaborating Centre for Mental Health, 2005). To berated clinically important, an early intervention had todemonstrate an effect size of >0.5 for continuous out-comes for wait list control comparisons, >0.4 for pla-cebo control comparisons and >0.2 for activetreatment control comparisons. For relative risk out-comes an effect of <0.8 was required. When only onestudy, evaluating a specific intervention, was availableits findings could not be judged as clinically important,unless the sample size was large (>300 participants).Non-inferiority RCT evidence alone was not sufficientto recommend an intervention as clinically important.
4 N. P. ROBERTS ET AL.
Following the procedure undertaken previously(Roberts et al., 2009), to determine the impact of qualityon outcome we decided that we that we would under-take a sensitivity analysis for allocation concealment.Inadequate allocation concealment has been found tohave influence the degree of effect in research trials andis thought to be one of the more important features ofrisk of bias (Hewitt, Hahn, Torgerson, Watson, &Bland, 2005). We therefore decided that we wouldinvestigate whether there was any indication of differ-ential treatment effects through a sensitivity analysis tosee if there was a change in the magnitude of effect andconfidence intervals, excluding studies rated to havea high or unclear risk of bias for allocation concealment.
3. Results
Figure one displays the results of the systematic searches.In addition to the 25 studies and two long-term outcomestudies included in the previous review, 6704 additionaltitles and abstracts were identified as a result of the searchprocess and 204 papers were reviewed in detail by two ofthe authors independently to establish if they met thespecified inclusion criteria. Thirty-six new studies werefound tomeet the inclusion criteria along with one paperreporting long term follow-up data for one of the newlyidentified studies, giving a total of 61 studies plus threelong-term follow-up studies. Twenty seven of the 61studies evaluated preventative interventions, aimed atanyone exposed to the relevant traumatic event; theother 34 studies evaluated early treatment interventions
in individuals with early traumatic stress symptoms; ofthese 14 were studies where participants met diagnosisfor ASD or PTSD. Fifty-nine studies were reported inEnglish, one was in French (Andre, Lelord, Legeron,Reignier, & Delattre, 1997) and one in Persian(Taghizadeh, Jafarbegloo, Arbabi, & Faghihzadeh,2008). A flow diagram of the systematic review can beseen in Figure 1. The characteristics of all studies identi-fied in this search and the previous review are describedin Table 1, with inclusion and exclusion criteria in TableS1 (see online supplement).
3.1. Synthesis of results
The outcomes for individual studies are shown inTable 1. The post intervention and follow-up results ofthe meta-analyses for comparisons that included morethan one study are shown in Table 2 with examples ofForest plots in Figures 2 and 3. The outcomes reportedare severity of PTSD and rates of PTSD.
3.1.1. Studies offering intervention to individualsinvolved in a traumatic event irrespective of theirsymptomsTwenty-seven studies (Als et al., 2015; Biggs et al., 2016;Borghini et al., 2014; Brom et al., 1993; Brunet et al., 2013;Cox et al., 2018; Curtis et al., 2016; Gamble, 2010; Gambleet al., 2005; Gidron et al., 2001, 2007; Holmes et al., 2007;Irvine et al., 2011; Jensen et al., 2016; Jones et al., 2010;Kazak et al., 2005; Lindwall et al., 2014; Marchand et al.,2006; Mouthaan et al., 2013; Rothbaum et al., 2012;
Figure 1. Flow diagram of the systematic review.
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 5
Table1.
Descriptio
nof
includ
edstud
ies.
Source
andCo
untry
Interventio
nandCo
ndition
s
MeanNum
ber
ofSessions
Attend
edPopu
latio
n
TimeSince
Traumaat
Startof
Interventio
nSeverityCriterio
n
TraumaticStress
Outcome
Measures
Rand
omized
(n):
Completers(n)
Follow-upPerio
dSign
ificant
Differences
Als,Nadel,C
ooper,
Vickers,and
Garralda,2015
UK
Teleph
onesupp
orted
psycho
educationvs.TAU
Interventio
nwas
self-directed
Parentsof
children
admitted
toapaediatric
intensivecare
unit
(ICU)
With
in7days
ofdischarge.
Non
eIES
31:2
33–6po
stdischarge
Neutral
Andreet
al.,1997
France
Upto
6sessions
ofCB
Tvs.
usualcare
2.35
Assaultedbu
sdrivers
recruitedviaan
urbanbu
scompany
Atleast14
days
Non
eIES
132:
6mon
ths
Neutral
Ben-Zion
etal.,2018
Israel
Dailycompu
terized
neurob
ehavioraltraining
(CNT)
for30
days
vsacompu
terized
games
controlvsareadingtask
control
Interventio
nwas
compu
terized.
Usage
was
notrepo
rted
Physicalinjury
from
civiliantrauma
recruitedfrom
generalh
ospital
Atleast7days
Prob
able
PTSD
diagno
sis
CAPS,
CAPS-5
97:5
2were
identifiedas
completers.
3and6mon
thspo
sttrauma
CNTwas
repo
rted
tobe
better
than
the
combinedcontrolsbu
tanalysiswas
only
cond
uctedon
those
completing
interventio
n.Bigg
set
al.,2016
USA
Four
2-ho
urinteractivegrou
pbasedsessions
basedon
Psycho
logicalFirstAidvs.
assessmenton
ly
2.22
Military
mortuary
attend
ants
returningfrom
deploymentin
the
MiddleEast
One
mon
thNon
ePC
L126:
125
2,3,
4,7,
and
10mon
thspo
stdeployment
Neutral
Bisson
,Sheph
erd,
Joy,Prob
ert,and
New
combe,2
004
UK
Four
60min.session
sof
expo
sure
basedCB
Tvs.
standard
care
3.30
Physicalinjury
from
civiliantrauma
recruitedfrom
aho
spitala
ccident
andem
ergencyun
it
5–10
weeks
Acute
psycho
logical
distress
CAPS,IES
152:
124
completed
to3mon
ths
3and13
mon
thspo
sttrauma
CBT-Tbetter
than
standard
care
at13
mon
thson
ly
Borghini
etal.,2014
Switzerland
Three60
minuteparenting
sessions
over
6mon
thsvs.
standard
care
Not
repo
rted
Mothersof
infants
born
prem
aturely
recruitedthroug
haneon
atal
intensive
care
unit
With
inon
eweek
Non
ePerin
atalPTSD
Questionn
aire
(PPQ
)
60:5
542
weeks
post
conceptio
nand4
and12
mon
ths
correctedinfant
birth.
Neutral
Brom
,Kleber,and
Hofman,1
993
Netherland
s
Upto
sixsessions
ofindividu
alpreventativecoun
selling
vs.
mon
itorin
ggrou
p
Not
repo
rted
Outpatient
victimsof
MVA
recruited
throug
hpo
lice
records.
Not
repo
rted
Non
eIES,TSI
738rand
omized,
151agreed
toenterstud
y:121
completed
3mon
thspo
sttreatm
ent
Neutral
Brun
et,D
esGroseilliers,
Cordova,and
Ruzek,2013
Canada
Twosessions
ofdyadicCB
Tvs.
assessmenton
lyNot
repo
rted
Physicalinjury
from
civiliantrauma
recruitedfrom
emergency
departments
ofpu
blicho
spitals
Mean26
days
Non
eIES-R,
CAPS
83rand
omized:6
6completed
asperprotocol
Posttreatm
ent,
DyadicCB
Tbetter
than
assessmenton
ly
Bryant,H
arvey,Dang,
Sackville,and
Basten,1
998
Australia
Five
90min.w
eeklysessions
ofexpo
sure
basedCB
Tvs
supp
ortivecoun
selling
Not
repo
rted
Outpatientsrecruited
from
aho
spital
PTSD
clinic
followingMVA
orindu
strialaccident
Mean9.9days
(CBT);10.3
days
SC
AcuteStress
Disorder
IES,CIDIP
TSD
mod
ule
Unclear:2
4completed
6mon
thsand4years
post
trauma
CBT-Tbetter
than
SC
(Con
tinued)
6 N. P. ROBERTS ET AL.
Table1.
(Con
tinued).
Source
andCo
untry
Interventio
nandCo
ndition
s
MeanNum
ber
ofSessions
Attend
edPopu
latio
n
TimeSince
Traumaat
Startof
Interventio
nSeverityCriterio
n
TraumaticStress
Outcome
Measures
Rand
omized
(n):
Completers(n)
Follow-upPerio
dSign
ificant
Differences
Bryant,Sackville,
Dang,
Mou
lds,and
Guthrie,1
999
Australia
Five
90min.w
eeklysessions
ofprolon
gedexpo
sure
orprolon
gedexpo
sure
plus
anxietymanagem
entvs.
supp
ortivecoun
selling
Not
repo
rted
Outpatientsrecruited
from
aho
spital
PTSD
clinic
followingMVA
orno
n-sexualassault
Mean10.3
days
(exposureplus
anxmgm
t),
10.0
days
(PE),
10.6
days
(SC)
AcuteStress
Disorder
CAPS,IES
56:4
5completed
6mon
thsand4years
post
trauma
CBT-TandCB
T-Tplus
AMbetter
than
SC
Bryant,M
oulds,
Guthrie,and
Nixon
,2003
Australia
Five
90min.w
eeklysessions
ofexpo
sure
basedCB
Tvs.
supp
ortivecoun
selling
Not
repo
rted
Outpatientswith
mild
traumaticbrain
injury
from
MVA
orno
n-sexualassault
recruitedfrom
aho
spitalP
TSD
clinic
2weeks
AcuteStress
Disorder
CAPS,IES
24:2
4completed
Posttreatm
entand
6mon
thspo
sttrauma
CBT-Tbetter
than
SC
Bryant,M
oulds,
Guthrie,and
Nixon
,2005
Australia
Six90
min.session
sof
expo
sure
basedCB
Tor
CBT
plus
hypn
osisvs.sup
portive
coun
selling
Not
repo
rted
Outpatientsfollowing
MVA
orno
n-sexual
assaultrecruited
from
aho
spital
PTSD
clinic
Mean15.8
days
(CBT);13.5
days
(CBT-hypno
sis);
14.0
days
(SC)
AcuteStress
Disorder
CAPS,IES
87:6
9completed
Posttreatm
entand
6mon
thsand
3yearspo
sttrauma
CBT-TandCB
T-Tplus
hypn
osisbetter
than
SC.
Bryant
etal.,2008
Australia
Five
90min
sessions
ofexpo
sure
therapyor
cogn
itive
restructuringvs.
waitin
glist
Not
repo
rted
Outpatient
victimsof
civiliantrauma
recruitedfrom
aho
spitaltraum
atic
stress
service
Mean22.8
days
AcuteStress
Disorder
CAPS,IES
69completed
Posttreatm
entand
6mon
thspo
sttrauma
Expo
sure
therapyand
Cogn
itive
restructuring
better
than
WL.ET
better
than
CR
Bugg
,Turpin,
Mason
,andScho
les,2009
UK
One
face
toface
andtwo
teleph
onesessions
with
atraumarelatedwriting
task
andinform
ation
interventio
nvs
inform
ation
only
Not
repo
rted
Outpatient
victimsof
MVA
,occup
ational
injury
orassault
recruitedfrom
aho
spitala
ccident
andem
ergency
clinic
5–6weeks
AcuteStress
Disorder
PDS
148rand
omized:
67availableto
initialfollow-up
3and6mon
thspo
sttrauma
Neutral
Cernvall,Carlb
ring,
Ljun
gman,
Ljun
gman,and
vonEssen,
2015
Sweden
Tenweeks
oftherapist
supp
ortedinternet
andCB
Tbasedgu
ided
self-help
vs.
assessmenton
ly
Not
repo
rted
Parentsof
children
with
cancer
recruitedfrom
paediatricon
cology
centres
Not
repo
rted
PTSD
symptom
positive
PCL-C
58:3
7Post-treatment
Guidedself-help
was
better
than
assessmenton
ly
Coxet
al.,2018
USA
Six30
minuteteleph
oneand
web
CBTbasedsessions
ofcoping
skilltraining
(CST)
vs.edu
catio
non
ly
2.7forCST;0.8
foreducation
only
Patientsadmitted
toan
ICUand
receiving>
48ho
ursof
mechanical
ventilatio
n
2weeks
post
discharge
Non
eIES-R
175:
136
3and6mon
thspo
stbaseline
Neutral
Curtiset
al.,2016
USA
Provisionof
aninpatient
patient/fam
ilycommun
icationfacilitator
vs.u
sualcare
9.4contactsper
family
Family
mem
bersof
patientsin
anICU
Rand
omization
occurred
following
admission
Non
ePC
L268:
133
3and6mon
ths
followingdeathor
dischargeof
the
patient
NeutralforPTSD
(Con
tinued)
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 7
Table1.
(Con
tinued).
Source
andCo
untry
Interventio
nandCo
ndition
s
MeanNum
ber
ofSessions
Attend
edPopu
latio
n
TimeSince
Traumaat
Startof
Interventio
nSeverityCriterio
n
TraumaticStress
Outcome
Measures
Rand
omized
(n):
Completers(n)
Follow-upPerio
dSign
ificant
Differences
Echebu
rua,de
Corral,
Sarasua,and
Zubizarreta,1996
Spain
Five
60min.session
ofexpo
sure
basedCB
Tvs.
relaxatio
n
Not
repo
rted
Femalevictimsof
rape
orsexualassault
recruitedfrom
apsycho
logical
coun
selling
centre
forwom
en
1.4mon
ths
AcutePTSD
Scaleof
Severity
ofPTSD
Symptom
s,
20:2
0completed
Post
treatm
ent,3,
6and12
mon
thspo
sttreatm
ent
CBT-Tbetter
than
relaxatio
nat
12mon
thfollow-upon
ly
Ehlerset
al.,2003
UK
Twelve
plus
three90
min.
sessions
oftraumafocused
CBTor
self-help
bookletvs.
waitin
glist
11.4
Outpatient
victimsof
MVA
recruitedfrom
locala
ccidentand
emergency
departments
4mon
ths
Acuteandchronic
PTSD
CAPS,P
DS
85:8
0completed
12participants
met
criteria
for
acutePTSD
and
wereinclud
edin
thisreview
.All
12completed
3and9mon
thspo
stbaseline
CBT-Tbetter
than
self
help
bookletandWL
Foa,Zoellner,and
Feeny,2006
USA
Four
2ho
ursessions
ofexpo
sure
basedCB
Tor
supp
ortivecoun
selling
vs.
continuo
usassessment
Not
repo
rted
Femalevictimsof
sexualandno
n-sexualassault
recruitedvia
emergencyroom
s,po
liceofficers,
medical
profession
als,local
victim
assistance
agencies,and
media
advertisem
ents
20.5
days
toassessment
PTSD
symptom
criteria
SCID-PTSD,P
SSI
90:6
6completed
Posttreatm
ent,2,3,6,
9and12
mon
ths
post
treatm
ent
Neutral
Freedm
an,n
.d.
Israel;Freedman,
Dayan,K
imelman,
Weissman,and
Eitan2015
Five
sessions
ofvirtualreality
andCB
Tbasedvs.w
aitin
glist
Not
repo
rted
Motor
vehicleaccident
(MVA
)recruitedvia
anem
ergencyroom
14days
toassessment
PTSD
symptom
positive
CAPS-5
14:1
4Post
treatm
ent,6and
12mon
ths
Neutral
Freedm
an,inpress
Israel
Five
sessions
ofteleph
one
basedCB
Tvs.w
aitin
glist
Not
repo
rted
Physicalinjury
from
civiliantrauma
recruitedvia
aho
spital
emergency
department
16days
toassessment
Diagn
osisforacute
PTSD
apartfrom
thedu
ratio
ncriteria
CAPS
139:
number
completingno
tclear
3and7mon
thspo
sttrauma
Neutral
Freyth,Elsesser,
Lohrmann,
and
Sartory,2010
Germany
Three90
minutesessions
ofexpo
sure
basedCB
Tvs
supp
ortivecoun
selling
Not
repo
rted
Vario
ustrauma
expo
sedou
tpatients
recruitedfrom
aun
iversity
psycho
logy
department
outpatient
treatm
entcentre
20.5
days
toassessment
AcuteStress
Disorder
IES-R
46:4
0Posttreatm
entand
3mon
thspo
sttreatm
ent
Neutral
(Con
tinued)
8 N. P. ROBERTS ET AL.
Table1.
(Con
tinued).
Source
andCo
untry
Interventio
nandCo
ndition
s
MeanNum
ber
ofSessions
Attend
edPopu
latio
n
TimeSince
Traumaat
Startof
Interventio
nSeverityCriterio
n
TraumaticStress
Outcome
Measures
Rand
omized
(n):
Completers(n)
Follow-upPerio
dSign
ificant
Differences
Gam
bleet
al.,2005
Australia
1sessionof
face
toface
coun
selling
and1sessionof
teleph
onecoun
selling
lastingup
to60
minsvs
treatm
entas
usual
Not
repo
rted
Mothersrecruitedvia
anante-natalclinic
followingtraumatic
birth
With
in72
hours
Non
eMINI-P
TSD
103:
102
completed
initialfollow-up,
103completed
3mon
thfollow-
up
4–6weeks
and
3mon
thspo
st-
partum
Interventio
nbetter
than
treatm
entas
usualat
3mon
thson
ly
Gam
ble,2010
Australia
1sessionof
face
toface
coun
selling
and1sessionof
teleph
onecoun
selling
vsparentingsupp
ort
Not
repo
rted
Mothersrecruitedvia
anante-natalclinic
followingtraumatic
birth
72ho
urs
Non
ePD
S262:
219
6weeks,6
and
12mon
thspo
st-
partum
Neutral
Gidronet
al.,2001
Israel
Twosessions
ofMem
ory
structuringinterventio
nvs.
supp
ortivelistening
Not
repo
rted
Outpatient
victimsof
anMVA
recruited
viaan
emergency
department.
24ho
urs
Heartrate
greater
than
95beats
perminutein
emergency
room
PDS
Num
ber
rand
omized
unclear:17
completed
3–4mon
thspo
sttrauma
Mem
orystructuring
interventio
nbetter
than
supp
ortive
listening
Gidronet
al.,2007
Israel
Twosessions
ofMem
ory
structuringinterventio
nvs.
supp
ortivelistening
Not
repo
rted
Outpatient
victimsof
anMVA
recruited
viaaun
iversity
medicalcentre.
With
in48
hours
Heartrate
greater
than
95beats
perminutein
emergency
room
.
PDS
Num
ber
rand
omized
unclear:34
completed
3mon
thspo
sttrauma
Neutral
Holmes
etal.,2007
Australia
Sixsessions
ofInterpersonal
Coun
selling
vs.assessm
ent
only
3.53
Major
physical
trauma
recruitedvia
aho
spitaltraum
acentre
Screening
occurred
at2weeks.
Non
ePC
L90:8
427
of51
completed
interventio
n
3and6mon
thspo
sttreatm
ent
Neutral
Irvineet
al.,2011
Canada
Eigh
tsessions
ofteleph
one
basedCB
Tvs.treatmentas
usual
Not
repo
rted
Patientsreceiving
implantable
cardioverter
defib
rillator
transplant
recruited
viaaho
spital
Unclear
–no
rmallysoon
afterdischarge
Non
eIES-R
193:
171(a
further
8participants
died)
6and12
mon
thspo
stbaseline
Interventio
nwas
better
than
treatm
entas
usualat6and
12mon
thsforwom
enandat
12mon
thsfor
men.
Jarero,A
rtigas,and
Luber,2011
Mexico
One
130minutesessionof
EMDRvs
delayedtreatm
ent
1Earthq
uake
survivors
recruitedvia
aprivatecompany
16days
Screened
positive
forPTSD
IES
18:1
8Posttreatm
ent
EMDRwas
better
than
delayedtreatm
ent
Jarero,U
ribe,Artig
as,
andGivaudan,
2015
Mexico
Two60
minutesessions
ofEM
DRvs
delayedtreatm
ent
Unclear
Expo
sure
toafatal
factoryexplosion
25days
Screened
positive
forPTSD
SPRINT
Num
ber
rand
omized
unclear:25
completed
Posttreatm
ent
EMDRwas
better
than
delayedtreatm
ent
Jensen
etal.,2016
Denmark
Threesessions
ofCB
Tbased
nurseledpsycho
logical
interventio
nvs.u
sualcare
1.92;3
4interventio
npatientsdied
durin
gthe
interventio
nperio
d
Patientsadmitted
toICUrequ
iring
mechanical
ventilatio
n
With
inon
emon
thof
discharge
Non
eHarvard
Trauma
Questionn
aire
386:
235
3and12
mon
thspo
stdischarge
Neutral
(Con
tinued)
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 9
Table1.
(Con
tinued).
Source
andCo
untry
Interventio
nandCo
ndition
s
MeanNum
ber
ofSessions
Attend
edPopu
latio
n
TimeSince
Traumaat
Startof
Interventio
nSeverityCriterio
n
TraumaticStress
Outcome
Measures
Rand
omized
(n):
Completers(n)
Follow-upPerio
dSign
ificant
Differences
Joneset
al.,2010
Denmark,Italy,
Norway,P
ortugal,
Sweden,U
K
Feedback
from
an(IC
U)
admission
sdiaryvs.delayed
feedback
Allrando
mized
patients
attend
edtheir
feedback
session
Admission
toICU≥
72ho
urs
Feedback
was
provided
at1mon
thpo
stdischarge
Non
ePD
S,PTSS-14
352:
322
3mon
thspo
stdischarge
Diary
feedback
was
better
than
delayed
feedback
Kazaket
al.,2005
USA
Three45
min
sessions
ofadaptedCB
Tandfamily
therapyinterventio
nvs
treatm
entas
usual
Primarycare
givers:2
.22
Second
ary
care
givers
2.33
38caregiversand
parentsof
children
newlydiagno
sed
with
cancer
recruitedfrom
achildren’sho
spital
oncology
service.
Median6days,
rang
e0–10
days
Non
eIES-R
38:3
1completed
availableto
follow-up
2mon
thspo
sttreatm
ent
Neutral
Lind
walle
tal.,2014*
USA
Threesessions
ofparent
and
child
targeted
psycho
education,
massage,
relaxatio
nandgu
ided
imageryvs.u
sualcare
Not
repo
rted
Parentsof
children
undergoing
stem
cellor
bone
marrow
transplantation
recruitedvia
paediatricstem
cell
transplantation
centres
Unclear.
Recruitm
ent
occurred
prior
totransplantation.
Non
eIES-R
113:
24weeks
post
admission
Neutral
Marchandet
al.,2006
Canada
Two1ho
ursessions
ofadaptedcriticalincident
stress
debriefin
gvs
ano
interventio
ncontrolg
roup
Not
repo
rted
Outpatient
victimsof
armed
robb
ery
recruitedvia
aconveniencestore
chain.
11.21days
Meetcriterio
nA1
andA2
forPTSD
SCID,IES
75:6
1availableat
1mon
thfollow-
up
1and3mon
thspo
stbaseline
Interventio
nbetter
than
adaptedCISD
initially
only
Mou
thaanet
al.,2013
Netherland
sSelf-gu
ided
CBTbased
internet
interventio
nvs
care
asusual
Meanlog-ins
was
1.7.
77.5%
logg
edin
once
ormore.
Hospitalized
severe
injury
patients
recruitedvia
atraumacentre
1weekpo
stinjury
Non
eCA
PS,IES-R
300:
231
completed
1mon
thassessment,189
completed
3mon
ths
assessment
1,3,12
and12
mon
ths
postinjury
Neutral
Nixon
,2012
Australia
Six90
minutesessions
ofcogn
itive
processing
therapyvs.sup
portive
coun
selling
Not
repo
rted
Mainlyself-referring
assaultvictims
recruitedvia
advertising,
victims
supp
ortagencies,
police,andvia
generalm
ediaalerts
Screening
occurred
with
in4weeks
ASD
CAPS,P
DS
30:2
1Post-treatmentand
6mon
ths
Neutral
Nixon
etal.,2016
Australia
Six90
minutesessions
ofcogn
itive
processing
therapyvs.sup
portive
coun
selling
3.5
Rape
andsexual
assaultsurvivors
recruitedfrom
arape
andsexual
assaultcrisiscentre
Screening
occurred
with
in4weeks
ASD
CAPS,P
CL-S
49:3
2Post-treatment,3,
6and12
mon
ths
Neutral
(Con
tinued)
10 N. P. ROBERTS ET AL.
Table1.
(Con
tinued).
Source
andCo
untry
Interventio
nandCo
ndition
s
MeanNum
ber
ofSessions
Attend
edPopu
latio
n
TimeSince
Traumaat
Startof
Interventio
nSeverityCriterio
n
TraumaticStress
Outcome
Measures
Rand
omized
(n):
Completers(n)
Follow-upPerio
dSign
ificant
Differences
O’Don
nellet
al.,2012
Australia
Upto
10sessions
ofCB
Tbasedsteppedcare
vs.
usualcare
6.3
MVA
andassault
recruitedfrom
traumaun
its
Finalscreening
andassessment
occurred
after
4weeks
Clinically
sign
ificant
symptom
sof
PTSD
,depression
oranxiety
CAPS
46:4
26and12
mon
thspo
stbaseline
CBTwas
better
than
usualcare
O’Donnell,Lau,
How
ard,and
Alkemadeet
al.,
n.d.
Australia
Upto
10sessions
ofteleph
one
CBTvs.u
sualcare.
6.2
Traumaun
itpatients
ofMVA
,accidentor
assaultrecruited
from
trauma
services
Finalscreening
andassessment
occurred
after
4weeks
Clinically
sign
ificant
mentalh
ealth
prob
lems
CAPS
61:5
46and12
mon
thspo
stinjury
Neutral
Öst,P
auno
vic,and
Gillow
,n.d.
Sweden
Sixteen60
min.session
sof
expo
sure
basedCB
Tvs.
waitin
glist
8.7
Outpatient
victimsof
violentcrime
recruitedthroug
hlocalp
sychiatric
units
andthepo
lice
6.8weeks
AcutePTSD
CAPS,IES-R
43:4
1Posttreatm
enton
lyCB
T-Tbetter
than
wait
list
Rothbaum
etal.,
2012
USA
Three60
min.session
sof
mod
ified
prolon
ged
expo
sure
vs.assessm
ent
only
2.61
Traumaexpo
sed
individu
alsadmitted
toaho
spital
emergency
department
72ho
urs
Non
ePSS-I,PD
S137:
102
4and12
weeks
post
enrolment
Mixed
-CBT-T
was
better
than
waitin
glistfor
PSS-Iscoresbu
tno
tPD
S
Ryding
,Wijm
a,and
Wijm
a,1998
Sweden
Twogrou
psessions
ofcoun
selling
andeducation
vstreatm
entas
usual.
Not
repo
rted
Wom
enfollowing
emergency
caesareansection
recruitedvia
aho
spitalo
bstetrics
andgynaecolog
ydepartment
Not
clearly
stated,
afewdays
after
giving
birth
Non
eIES
106:
100
completed
6mon
thspo
st-partum
Neutral
Ryding
,Wiren,
Johansson,
Ceder,
andDahlstrom
,2004
Sweden
Twogrou
psessions
ofcoun
selling
andeducation
vstreatm
entas
usual.
Not
repo
rted
Wom
enfollowing
emergency
caesareansection
recruitedvia
aho
spitalo
bstetrics
andgynaecolog
ydepartment
2mon
ths
Non
eIES
162:
147available
atinitialfollow-
up
6mon
thspo
st-partum
Neutral
Shalev
etal.,2012**
Israel
Twelve
90minutesessions
ofprolon
gedexpo
sure
(PE)
vscogn
itive
therapy(CT)
vswaitin
glist
Not
repo
rted
MainlyMVA
andacts
ofterrorism
survivorsrecruited
viaho
spitals
emergencyservices
Recruitm
ent
occurred
atameanof
19.8
dayafter
trauma
PTSD
orpartial
PTSD
CAPS,P
SS-R
196:
168available
atinitialfollow-
up
4and9mon
thspo
sttrauma
PEandCT
werebetter
than
waitlist.There
was
nodiffe
rence
betweenPE
andCT
Shapiro
andLaub
,2015
Israel
Two90
minutesessions
ofEM
DRvs
delayedtreatm
ent
Not
repo
rted
Survivorsof
amissile
attack
recruited
throug
hthe
commun
ity
Thestud
ybegan
6weeks
after
theincident
Screened
positive
forPTSD
and/or
depression
IES-R
17:1
7Post-treatment
EMDRbetter
than
delayedtreatm
ent
(Con
tinued)
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 11
Table1.
(Con
tinued).
Source
andCo
untry
Interventio
nandCo
ndition
s
MeanNum
ber
ofSessions
Attend
edPopu
latio
n
TimeSince
Traumaat
Startof
Interventio
nSeverityCriterio
n
TraumaticStress
Outcome
Measures
Rand
omized
(n):
Completers(n)
Follow-upPerio
dSign
ificant
Differences
Shapiro
,Laub,
and
Rosenb
lat,2018
Israel
Three90
minutesessions
ofEM
DRvs
delayedtreatm
ent
Not
repo
rted
Treatm
entseeking
individu
als
expo
suredto
arocket
attack
Recruitm
ent
began
2–3mon
ths
afterthe
incident.
Individu
als
presentin
gseeking
treatm
ent
PCL-5
25:2
4Post-treatment
EMDRbetter
than
delayedtreatm
ent
Shaw
etal.,2013
USA
Six50
minutesessions
ofCB
T-Tvs.u
sualcare
Not
repo
rted
Mothersof
prem
ature
infantsrecruited
from
neon
atal
intensivecare
units
Baseline
assessmentwas
at1–2weeks
Screened
positive
forAS
D,
depression
,anxietyor
acute
stress
DTS
105:
98Post-treatment
CBT-Tbetter
than
usual
care
Sijbrand
ijet
al.,2007
Netherland
sFour
2ho
urweeklysessions
ofexpo
sure
basedCB
Tvs.
waitin
glist
3.30
Outpatient
victimsof
civiliantraumatic
eventsreferred
via
theem
ergency
room
andtrauma
unitof
anacadem
icmedicalcentre,and
byvictim
supp
ort
workers,g
eneral
practitioners,and
company
doctors
40days
AcutePTSD
,(some
participants
did
notmeetthe
onsetcriterio
n)
SI-PTSD
143:
117
completed
1weekand4mon
ths
post
treatm
ent
Neutral
Skog
stad,H
em,
Sand
vik,and
Ekeberg,
2015
Norway
Upto
660
minutesessions
ofnu
rseledCB
Tvs.u
sualcare
Not
repo
rted
Outpatient
victimsof
traumarecruited
from
aho
spital
atraumareferral
centre
Before
3mon
ths
Screening
positivelyfor
PTSD
ontheIES
IES
145:
853and12
mon
thspo
stinjury
Neutral
Tagh
izadeh
etal.,
2008
Iran
Upto
6weeks
of60
minutes
sessions
ofcoun
selling
vs.
usualcare
Not
repo
rted
Traumaticbirth
recruitedvia
aho
spital
With
in72
hours
Non
eIES
300:
numberof
completersno
trepo
rted
4–6weeks
and
3mon
thspo
st-
partum
Neutralat
4–6weeks,
coun
selling
better
than
usualcareat
3mon
ths
vanEm
merik,
Kamph
uis,and
Emmelkamp,
2008
Netherland
s
Five
90minutesessions
ofexpo
sure
basedCB
T,or
awritinginterventio
nvs.
waitin
glistcond
ition
.
Not
repo
rted
Outpatientsfollowing
civiliantrauma
referred
toaun
iversity
clinical
psycho
logy
department
Meanof
119.40
days
ASD,acute
PTSD
OrchronicPTSD
IES
125:
85completed
66eligible
forthis
review
:47
completed
Noconsistent
pointof
long
-term
follow-up
CBT-Tandwriting
interventio
nbetter
than
waitlist
Wanget
al.,2015
China
Eigh
t40
minutes
sessions
ofgrou
pbasedcreativearts
usingdraw
ingandcreative
writingvs
waitin
glist
Not
repo
rted
MVA
victimsrecruited
viaaho
spital
emergency
department
Not
clearly
stated.
Recruitm
ent
occurred
at96
hourspo
stinjury
Non
eCA
PS,IES-R
52:4
62,
6and12
mon
ths
post
enrolment
Neutral
Wagner,Zatzick,
Ghesquiere,and
Jurkovich,
2007
USA
Upto
six90
min.session
sof
behaviou
rala
ctivationand
treatm
entas
usualvs.
treatm
entas
usual.
5.75
Inpatientsfollowing
civiliantrauma
recruitedfrom
amedicalwardin
atraumacentre
>4weeks
AcutePTSD
PCL
8:8completed
3mon
thspo
st-traum
aNeutral
(Con
tinued)
12 N. P. ROBERTS ET AL.
Table1.
(Con
tinued).
Source
andCo
untry
Interventio
nandCo
ndition
s
MeanNum
ber
ofSessions
Attend
edPopu
latio
n
TimeSince
Traumaat
Startof
Interventio
nSeverityCriterio
n
TraumaticStress
Outcome
Measures
Rand
omized
(n):
Completers(n)
Follow-upPerio
dSign
ificant
Differences
Wijesing
heet
al.,
2015
SriLanka
Psycho
educatione
session+
onesessionCB
Tvs.
psycho
educationon
lyvs.
assessmenton
ly
Not
repo
rted
Snakebite
victims
recruitedvia
aho
spital
Atdischargefrom
hospitala
fter
antivenom
treatm
ent
Non
ePSS-SR
225:
202
6mon
thspo
stdischarge
Neutral
Wu,Li,and
Cho,2014
Hon
gKong
Four
90minutesessions
ofCB
T-Tvs.a
self-helpbo
oklet
2.45
MVA
victimsrecruited
throug
hthe
emergency
departmentof
adistrictmedical
centre
Baseline
assessmentat
1mon
th
Traumaticstress
symptom
sat
1mon
th
IES-R
60:3
73and6mon
thspo
stMVA
Neutral
Zatzicket
al.,2001
USA
Collabo
rativecare
interventio
n,includ
ing
assign
mentto
trauma
supp
ortspecialistvs
usual
care
92minutes
ofclinicalcontact
Physicallyinjured
hospitalized
MVA
&assaultvictims
recruitedfrom
aho
spitaltraum
acentre
With
in1mon
thAllh
ospitalized
individu
als
PCL
34:2
6completed
1and4mon
thspo
stinjury
Neutral
Zatzicket
al.,2004
USA
Multifaceted
collabo
rativecare
forPTSD
andalcoho
labu
sevs
usualcare
10.7
hoursof
clinicalcontact
Physicallyinjured
hospitalized
MVA
&assaultvictims
recruitedfrom
aho
spitaltraum
acentre
Not
clearly
stated
butsoon
after
admission
Sign
ificant
symptom
sof
PTSD
and/or
depression
PCL
121:
106retained
at1mon
th,9
9retained
at12
mon
ths
1,3,
6and12
mon
ths
post
admission
Neutral
Zatzicket
al.,2013
USA
Multifaceted
collabo
rativecare
forPTSD
,alcoh
olabuseand
otherhigh
riskbehaviou
rsvs
usualcare
Median
13.2
hoursof
clinical
contact
Physicallyinjured
hospitalized
trauma
survivorsrecruited
from
aho
spital
traumacentre
Not
clearly
stated
butsoon
after
discharge
Screening
positivelyfor
PTSD
atadmission
and
discharge
CAPS,P
CL207:
164retained
at3mon
ths,
167retained
at12
mon
ths
1,3,
6,9and
12mon
thspo
stadmission
Collabo
rativecare
better
than
usualcare
Zatzicket
al.,2015
USA
Techno
logy
enhanced
collabo
rativecare
forPTSD
,alcoho
labu
seandother
high
riskbehaviou
rsvs
usualcare
Median
2.25
hoursof
clinical
contact
Physicallyinjured
hospitalized
trauma
survivorsrecruited
from
aho
spital
traumacentre.
Not
clearly
stated
butbegan
durin
gadmission
Screening
positivelyfor
PTSD
PCL
121:
108retained
at1mon
th,1
05retained
at6mon
ths
1,3,
and6mon
ths
post
admission
Neutral
*Thisstud
yinclud
edan
additio
nalarm
where
interventio
nwas
offeredon
lyto
thechild.D
atafrom
thisarm
areno
tinclud
ed**Thisstud
yinclud
edtwoadditio
nala
rmsevaluatin
gEscitalopram
andplacebomedication.
Dataforthesearmsareno
tinclud
edin
thistable.
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 13
Table2.
Summaryof
meta-analysisof
results
forinterventio
ns.
Comparison
Follow-up(and
contrib
utingstud
ies)
Trials(n)
Sample(n)
RelativeRisk
(95%
CI)
Standardized
MeanDifference
(95%
CI)
Grade
Ratin
g
Interven
tion
swithinon
emon
thforalle
xposed
tothetrau
ma
Briefindividu
alprocessing
therapiesvs
usualcare
(PTSDseverity)
Posttreatm
ent(Brom
etal.,1993;G
ambleet
al.,2005;M
archand
etal.,2006;R
othb
aum
etal.,2012)
3–6mon
thspo
sttrauma(Brom
etal.,1993;G
ambleet
al.,2005;
Marchandet
al.,2006;R
othb
aum
etal.,2012)
4 4465
466
0.04
(−0.34,0
.42)
-0.07(−0.25,0
.12)
Very
low
Very
low
Briefindividu
alprocessing
therapiesvs
usualcare
(PTSDdiagno
sis)
Posttreatm
ent(Gam
bleet
al.,2005;M
archandet
al.,2006;
Rothbaum
etal.,2012)
3–6mon
thspo
sttrauma(Gam
bleet
al.,2005;M
archandet
al.,2006;
Rothbaum
etal.,2012)
3 3262
251
1.10
(0.87,
1.40)
0.73
(0.44,
1.22)
Very
low
Very
low
Briefdyadictherapyvs
usualcare(PTSDseverity)
3–6mon
thspo
sttrauma(Brunetet
al.,2013;K
azak
etal.,2005)
2103
−0.41
(−0.81,−
0.02)*
Very
low
Briefindividu
altraumaprocessing
therapyvs
supp
ortivelistening
3–6mon
thspo
sttrauma(Gidronet
al.,2001;G
idronet
al.,2007)
251
−0.54
(−1.42,0
.34)
Very
low
Interven
tion
sbe
ginn
ingwithinthreemon
ths
forindividu
alswithtrau
matic
stress
symptom
sTraumafocusedCB
Tvs
waitlist(PTSDseverity)
Posttreatm
ent(Bissonet
al.,2004;B
ryantet
al.,2008;Ehlerset
al.,
2003;Foa
etal.,2006;Ö
stet
al.,n.d.;Shalevet
al.,2012;Shaw
etal.,2013;Sijbrand
ijet
al.,2007;van
Emmeriket
al.,2008)
3–6mon
thspo
sttrauma(Ehlerset
al.,2003;Foa
etal.,2006;Shalev
etal.,2012;Shaw
etal.,2013;Sijbrand
ijet
al.,2007)
7–12
mon
thspo
sttrauma(Bissonet
al.,2004;Foa
etal.,2006)
2yearspo
sttrauma(Shalevet
al.,2012)
9 5 2 1
746
420
213
67
−0.63
(−0.93,−
0.32)*
-0.30(−0.58,−
0.02)*
-0.25(−0.52,0
.02)
-0.03(−0.45,0
.51)
Low
Low
Low
Very
low
TraumafocusedCB
Tvs
waitlist(PTSDdiagno
sis)
Posttreatm
ent(Bissonet
al.,2004;B
ryantet
al.,2008;Ehlerset
al.,
2003;Foa
etal.,2006;Ö
stet
al.,n.d.;Shalevet
al.,2012;Sijbrand
ijet
al.,2007;van
Emmeriket
al.,2008)
3–6mon
thspo
sttrauma(Ehlerset
al.,2003;Foa
etal.,2006;Shalev
etal.,2012;Sijbrand
ijet
al.,2007)
7–12
mon
thspo
sttrauma(Bissonet
al.,2004;Foa
etal.,2006)
2+yearspo
sttrauma(Shalevet
al.,2012)
8 4 2 1
671
309
158
67
0.67
(0.47,
0.96)*
0.61
(0.46,
0.82)*
0.73
(0.42,
1.28)
0.91
(0.44,
1.90)
Mod
erate
Low
Very
low
Very
low
Cogn
itive
therapyvs
waitlist
(PTSDseverity)
Posttreatm
ent(Bryantet
al.,2008;Shalevet
al.,2012)
3–6mon
thspo
sttrauma(Shalevet
al.,2012)
2yearspo
sttrauma(Shalevet
al.,2012)
2 1 1
172
92 57
−0.68
(−1.00,−
0.35)*
-0.13(−0.55,0
.30)
0.05
(−0.47,0
.57)
Low
Very
low
Very
low
Cogn
itive
therapyvs
waitlist
(PTSDdiagno
sis)
Posttreatm
ent(Bryantet
al.,2008;Shalevet
al.,2012)
3–6mon
thspo
sttrauma(Shalevet
al.,2012)
2+yearspo
sttrauma(Shalevet
al.,2016)
2 1 1
172
133
57
0.66
(0.39,
1.12)
0.52
(0.30,
0.89)*
1.28
(0.63,
2.59)
Low
Very
low
Very
low
EMDRvs
waitlist(PTSDseverity)
Posttreatm
ent
484
−2.50
(−4.25,−
0.75)*
Very
low
Teleph
one-basedCB
T-Tvs
waitlist
(PTSDseverity)
Posttreatm
ent(Freedman,inpress;O’Don
nellet
al.,n.d.)
3–6mon
thspo
sttrauma(O’Don
nellet
al.,n.d.)
2 1191
610.06
(−0.22,0
.35)
0.28
(−0.22,0
.79)
Low
Very
low
Steppedcollabo
rativecare
vsusualcare(PTSD
severity)
1-mon
thpo
sttrauma(Zatzick
etal.,2013;Z
atzick
etal.,2015)
3–6mon
thspo
sttrauma(O’Don
nellet
al.,2012;Z
atzick
etal.,2013;
Zatzicket
al.,2015)
7–12
mon
thspo
sttrauma(O’Don
nellet
al.,2012;Zatzick
etal.,2013)
2 3 2
328
370
238
−0.05
(−0.27,0
.17)
-0.45(−0.65,−
0.24)*
-0.61(−1.41,0
.20)
Mod
erate
Mod
erate
Low
Steppedcollabo
rativecare
vsusualcare(PTSD
diagno
sis)
1-mon
thpo
sttrauma(Zatzick
etal.,2004)
3–6mon
thspo
sttrauma(O’Don
nellet
al.,2012;Zatzick
etal.,2004)
7–12
mon
thspo
sttrauma(O’Don
nellet
al.,2012;Zatzick
etal.,2004)
1 2 2
106
144
122
0.85
(0.42,
1.69)
0.42
(0.14,
1.26)
0.55
(0.28,
1.09)
Very
low
Very
low
Very
low
(Con
tinued)
14 N. P. ROBERTS ET AL.
Table2.
(Con
tinued).
Comparison
Follow-up(and
contrib
utingstud
ies)
Trials(n)
Sample(n)
RelativeRisk
(95%
CI)
Standardized
MeanDifference
(95%
CI)
Grade
Ratin
g
TraumaFocusedCB
Tvs
Supp
ortiveCo
unselling
(PTSDseverity)
Posttreatm
ent(Bryantet
al.,1998;B
ryantet
al.,2005;B
ryantet
al.,
1999;Bryante
tal.,2003;Foa
etal.,2006;Freythet
al.,2010;N
ixon
,2012;N
ixon
etal.,2016)
3–6mon
thsfollow-up(Bryantet
al.,1998;Bryantet
al.,2005;Bryant
etal.,1999;Bryantet
al.,2003;Foa
etal.,2006;Freythet
al.,2010;
Nixon
,2012;
Nixon
etal.,2016)
7–12
mon
thspo
sttrauma(Foa
etal.,2006;N
ixon
etal.,2016)
2+yearspo
sttrauma(Bryant,Mou
lds,&Nixon
,2003)
8 8 2 2
331
314
106
94
−0.61
(−1.01,−
0.22)*
-0.58(−0.87,−
0.28)*
-0.06(−0.45,0
.32)
-0.72(−1.16,−
0.28)*
Low
Low
Very
low
Very
low
TraumaFocusedCB
Tvs
Supp
ortiveCo
unselling
(PTSDdiagno
sis)
Posttreatm
ent(Bryantet
al.,1998;B
ryantet
al.,2005;B
ryantet
al.,
1999;B
ryantet
al.,2003;Foa
etal.,2006;N
ixon
etal.,2016)
3–6mon
thsfollow-up(Bryantet
al.,1998;Bryantet
al.,2005;B
ryant
etal.,1999;B
ryantet
al.,2003;Foa
etal.,2006)
2+yearspo
sttrauma(Bryantet
al.,2003)
6 5 2
281
200
170
0.61
(0.36,
1.04)
0.37
(0.20,
0.67)*
0.68
(0.48,
0.96)*
Low
Low
Very
low
TraumaFocusedCB
Tvs
self-help
(PTSDseverity)
Posttreatm
ent(Ehlerset
al.,2003;W
uet
al.,2014)
3–6mon
thsfollow-up(Ehlerset
al.,2003;W
uet
al.,2014)
2 247 63
−0.57
(−1.25,0
.11)
-0.59(−1.41,0
.22)
Very
low
Very
low
TraumaFocusedCB
Tvs
Cogn
itive
Therapy(PTSD
severity)
Posttreatm
ent(Bryantet
al.,2008;Shalevet
al.,2012)
3–6mon
thspo
sttrauma(Bryantet
al.,2008;Shalevet
al.,2012)
2+yearspo
sttrauma(Shalevet
al.,2016)
2 2 1
149
147
60
−0.19
(−0.52,0
.14)
-0.25(−0.58,0
.08)
-0.02(−0.53,0
.49)
Low
Low
Very
low
TraumaFocusedCB
Tvs
Cogn
itive
Therapy(PTSD
diagno
sis)
Posttreatm
ent(Bryantet
al.,2008;Shalevet
al.,2012)
3–6mon
thspo
sttrauma(Bryantet
al.,2008;Shalevet
al.,2012)
2+yearspo
sttrauma(Shalevet
al.,2016)
2 2 1
163
163
60
0.70
(0.40,
1.22)
0.87
(0.38,
1.97)
0.60
(0.20,
1.78)
Low
Low
Very
low
Interven
tion
sforindividu
alswithstress
disorder
orpo
st-traum
atic
stress
disorder
TraumaFocusedCB
Tvs
Waitlist(PTSDseverity)
Posttreatm
ent(Bryantet
al.,2008;Ehlerset
al.,2003;Ö
stet
al.,n.d.;
Shalev
etal.,2012;Sijbrand
ijet
al.,2007;van
Emmeriket
al.,2008)
3–6mon
thspo
sttrauma(Ehlerset
al.,2003;Shalevet
al.,2012)
2years+(Shalevet
al.,2012)
6 2 1
387
121
67
−0.89
(−1.23,−
0.56)*
-0.84(−2.49,0
.80)
0.03
(−0.45,0
.51)
Low
Very
low
Very
low
TraumaFocusedCB
Tvs
Waitlist(PTSDdiagno
sis)
Posttreatm
ent(Bryantet
al.,2008;Ehlerset
al.,2003;Ö
stet
al.,n.d.;
Shalev
etal.,2012;Sijbrand
ijet
al.,2007;van
Emmeriket
al.,2008)
3–6mon
thspo
sttrauma(Ehlerset
al.,2003;Shalevet
al.,2012)
2years+po
sttrauma(Shalevet
al.,2012)
6 2 1
410
168
67
0.54
(0.35,
0.82)*
0.59
(0.40,
0.87)
0.91
(0.44,
1.90)
Low
Very
low
Very
low
Cogn
itive
therapyvs
waitlist
(PTSDseverity)
Posttreatm
ent(Bryantet
al.,2008;Shalevet
al.,2012)
3–6mon
thspo
sttrauma(Shalevet
al.,2012)
2yearspo
sttrauma(Shalevet
al.,2012)
2 1 1
172
92 57
−0.68
(−1.00,−
0.35)*
-0.13(−0.55,0
.30)
0.05
(−0.47,0
.57)
Low
Very
low
Very
low
Cogn
itive
therapyvs
waitlist
(PTSDdiagno
sis)
Posttreatm
ent(Bryantet
al.,2008;Shalevet
al.,2012)
3–6mon
thspo
sttrauma(Shalevet
al.,2012)
2+yearspo
sttrauma(Shalevet
al.,2016)
2 1 1
172
133
57
0.66
(0.39,
1.12)
0.52
(0.30,
0.89)*
1.28
(0.63,
2.59)
Low
Very
low
Very
low
TraumaFocusedCB
Tvs
Supp
ortiveCo
unselling
(PTSDseverity)
Posttreatm
ent(Bryantet
al.,1998;B
ryantet
al.,2005;B
ryantet
al.,
1999;B
ryantet
al.,2003;N
ixon
,2012;
Nixon
etal.,2016)
3–6mon
thspo
sttrauma(Bryantet
al.,1998;B
ryantet
al.,2005;
Bryant
etal.,1999;B
ryantet
al.,2003;N
ixon
,2012;
Nixon
etal.,
2016)
7–12
mon
thspo
sttrauma(Nixon
etal.,2016)
2+yearspo
sttrauma(Bryantet
al.,2003;B
ryantet
al.,2006)
6 6 1 2
231
217
46 94
−0.75
(−1.03,−
0.47)*
-0.74(−1.03,−
0.45)*
-0.38(−0.96,0
.21)
-0.72(−1.16,−
0.28)*
Low
Low
Very
low
Very
low
(Con
tinued)
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 15
Ryding et al., 1998, 2004; Wang et al., 2015; Wijesingheet al., 2015; Zatzick et al., 2001) evaluated brief psychoso-cial interventions aimed at preventing PTSD in indivi-duals exposed to a specific traumatic event. All startedwithin one month of the trauma. Seven studies (Bromet al., 1993; Gamble et al., 2005; Gidron et al., 2001, 2007;Marchand et al., 2006; Rothbaum et al., 2012; Rydinget al., 1998) used an approach which we grouped as‘brief individual trauma processing’. These studies eval-uated a number of brief therapies that were theoreticallydiverse but shared similar core treatment components.These included: psychoeducation and therapist directedreliving of the index trauma to promote elaboration of thetrauma memory and help to contextualize or reframeaspects of the experience. We found no statistical differ-ence between brief individual trauma processingapproaches and usual care or a supportive listening con-trol intervention at any time point (see Figure 2). We didfind evidence to support the use of brief CBT baseddyadic therapy over treatment as usual, at 3 months(Brunet et al., 2013; Kazak et al., 2005) but this effectwas not judged clinically important. A single studyshowed a significant difference in PTSD severity for self-guided internet-based intervention over treatment asusual (Mouthaan et al., 2013) at 1 month (N = 300;SMD −0.38 CI −0.61 to −0.15; GRADE low) and3–6 months post trauma (N = 300; SMD −0.27 CI−0.50 to −0.04; GRADE low) but not at 7–12 months(N= 300 SMD0.00CI−0.23 to 0.23; GRADE low). Theseeffects were not judged clinically important. One singlestudy showed no significant difference for intensive carediaries over delayed access to intensive care diaries at3–6 months but did show a significant difference forPTSD diagnosis (N = 322; RR 0.38 CI 0.17 to 0.82;GRADE low).Another single study evaluating telephone-based CBT following cardioverter defibrillator transplant(Irvine et al., 2011) found no difference to usual care at3–6 months but there was a difference at 7–12 months(N = 185; SMD −0.38 CI −0.67 to −0.09; GRADE low).This effect was not judged clinically important.
No differences were found for group counselling(Ryding et al., 2004), a three step parenting interventionfollowing premature birth (Borghini et al., 2014), briefinterpersonal counselling (Holmes et al., 2007), commu-nication facilitator in an intensive care setting (Curtiset al., 2016), supported psychoeducation (Als et al.,2015), a nurse led intensive care recovery program(Jensen et al., 2016), or collaborative care (Zatzick et al.,2001). Six studies did not provide data that we were ableto interrogate because data were not adequately reportedin study papers and we were unable to obtain additionaldata from study authors (Andre et al., 1997; Biggs et al.,2016; Lindwall et al., 2014; Taghizadeh et al., 2008;Wanget al., 2015; Wijesinghe et al., 2015). Of these, one study(Taghizadeh et al., 2008) reported a difference in PTSDseverity for counselling at 3–6 months over usual care(N = 300) for women who had experienced a traumaticTa
ble2.
(Con
tinued).
Comparison
Follow-up(and
contrib
utingstud
ies)
Trials(n)
Sample(n)
RelativeRisk
(95%
CI)
Standardized
MeanDifference
(95%
CI)
Grade
Ratin
g
TraumaFocusedCB
Tvs
Supp
ortiveCo
unselling
(PTSDdiagno
sis)
Posttreatm
ent(Bryantet
al.,1998;B
ryantet
al.,2005;B
ryantet
al.,
1999;B
ryantet
al.,2003;N
ixon
,2012)
3–6mon
thspo
sttrauma(Bryantet
al.,1998;B
ryantet
al.,2005;
Bryant
etal.,1999;B
ryantet
al.,2003)
3–4years(Bryantet
al.,2003;B
ryantet
al.,2006)
5 4 2
221
158
170
0.30
(0.17,
0.53)*
0.26
(0.16,
0.45)*
0.68
(0.48,
0.96)*
Low
Low
Very
low
TraumaFocusedCB
Tvs
Cogn
itive
Therapy(PTSD
severity)
Posttreatm
ent(Bryantet
al.,2008;Shalevet
al.,2012)
3–6mon
thspo
sttrauma(Bryantet
al.,2008;Shalevet
al.,2012)
2+yearspo
sttrauma(Shalevet
al.,2016)
2 2 1
149
147
60
−0.19
(−0.52,0
.14)
-0.25(−0.58,0
.08)
-0.02(−0.53,0
.49)
Low
Low
Very
low
TraumaFocusedCB
Tvs
Cogn
itive
Therapy(PTSD
diagno
sis)
Posttreatm
ent(Bryantet
al.,2008;Shalevet
al.,2012)
3–6mon
thspo
sttrauma(Bryantet
al.,2008;Shalevet
al.,2012)
2+yearspo
sttrauma(Shalevet
al.,2016)
2 2 1
163
163
60
0.70
(0.40,
1.22)
0.87
(0.38,
1.97)
0.60
(0.20,
1.78)
Low
Low
Very
low
Relativerisk=of
diagno
sisof
PTSD
.1=sameas
control,<1=interventio
nbetter,>
1=controlb
etter.
Standardized
meandiffe
rence=of
continuo
usPTSD
symptom
score.IfSM
D=0thereisno
diffe
rencebetweentheinterventio
nandthecontrol.<0=interventio
nbetter,>
0=controlb
etter.
*Statisticallysign
ificant
diffe
renceat
p<0.05
level.
16 N. P. ROBERTS ET AL.
birth. Positive findings were not reported for PTSD out-comes in other studies.
3.1.2. Studies offering intervention to individualswith traumatic stress symptoms within threemonths of a traumatic eventThirty-four studies (Ben-Zion et al., 2018; Bissonet al., 2004; Bryant et al., 1998, 1999, 2003, 2005,2008; Bugg et al., 2009; Cernvall et al., 2015;Echeburua et al., 1996; Ehlers et al., 2003; Foa et al.,2006; Freedman, n.d., in press; Freyth et al., 2010;Jarero et al., 2011, 2015; Nixon, 2012; Nixon et al.,2016; O’Donnell et al., n.d., 2012; Öst et al., n.d.;
Shalev et al., 2012; Shapiro & Laub, 2015; Shapiroet al., 2018; Shaw et al., 2013; Sijbrandij et al., 2007;Skogstad et al., 2015; van Emmerik et al., 2008;Wagner et al., 2007; Wu et al., 2014; Zatzick et al.,2004, 2013, 2015) evaluated interventions for indivi-duals with traumatic stress symptoms beginningwithin three months of a traumatic event.Statistically significant differences were found infavour of CBT-T over wait list and supportive coun-selling at initial follow-up for PTSD severity (seeFigure 3). Findings for both comparisons were judgedto be clinically important. Follow-up data wereincomplete but statistically significant differences
Figure 2. Forest plot of PTSD severity, post treatment for studies offering intervention to individuals involved in a traumaticevent irrespective of their symptoms.
Figure 3. Forest plot of PTSD severity, post treatment for studies of interventions begun within three months with the aim ofpreventing PTSD or ongoing distress in individuals with traumatic stress symptoms.
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 17
were present at several time points. A post hoc sub-group analysis suggested that effects were largest forinterventions of 12 or more sessions (K = 3; N = 181;SMD −1.11 CI-1.62, −0.61) when compared againstwait list. Statistically significant differences for PTSDseverity were also found for cognitive therapy withoutexposure and EMDR over wait list at initial follow-up. One single study (van Emmerik et al., 2008)showed a significant difference for structured writingtherapy over wait list (N = 45; SMD −0.97 CI −1.59,−0.35; GRADE very low) but there was no differencewhen compared against psychoeducation only (Bugget al., 2009) in another single study. Another singlestudy (Cernvall et al., 2015) showed a significant dif-ference for internet-based guided self-help over waitlist (N = 58; SMD −0.66 CI −1.19, −0.13: GRADEvery low). Findings for cognitive therapy and EMDRwere judged as clinically important. No significantdifferences were found between telephone basedCBT-T and wait list or, from single studies of beha-vioural activation (Wagner et al., 2007) and internet-based virtual reality therapy over wait list (Freedman,n.d.). No difference was found between computerizedneurobehavioral training and a reading-based controlcondition (Ben-Zion et al., 2018). We founda significant effect for collaborative care over waitlist at 3–6 months post-trauma but there was noeffect at 1 month or 7–12 months. These effectswere not judged clinically important. In head tohead comparisons we found no difference betweenCBT-T and self-help or trauma focused CBT andcognitive therapy.
3.1.3. Studies offering intervention to individualswith a diagnosis of acute stress disorder or PTSDFourteen studies (Bryant et al., 1998, 1999, 2003, 2005,2008; Echeburua et al., 1996; Ehlers et al., 2003; Nixon,2012; Nixon et al., 2016; Öst et al., n.d.; Shalev et al.,2012; Sijbrandij et al., 2007; van Emmerik et al., 2008;Wagner et al., 2007) offered interventions to individualswith a diagnosis of acute stress disorder or PTSD,within three months of the traumatic event.Statistically significant differences were found in favourof CBT-T over a wait list control group and supportivecounselling post treatment. Follow-up data wereincomplete but statistically significant differences werepresent at some follow-up time points. There was alsoa significant difference in favour of cognitive therapyover waitlist. There was no difference in head to headcomparison between CBT-T and cognitive therapy.
3.2. Methodological quality of included studies
Risk of bias judgements for individual studies areshown in Table S2 (see online supplement). Thirty-sixstudies adequately described a method of allocationjudged to make no bias possible. Five studies were
considered to be at high risk of bias. Reporting ofadequate concealment procedures was present in 25studies, with six studies considered to be at high riskof bias. Adequate blinding of the assessor of outcomemeasures was present in 42 studies, with 4 studiesconsidered to be at high risk. Incomplete outcomedata was considered low risk in 26 studies, witha further 22 studies judged to be at high risk of bias.Twelve studies, all published since 2010, were judgedlow risk for selective reporting. The majority of otherstudies were of unclear risk, with three studies beingjudged at high risk. Forty studies were judged at highrisk for other bias. Reasons for possible other biasincluded author affiliation with one of the interventionsbeing tested, small sample size, use of measures withinadequate validation, non-manualized interventionand poor treatment adherence. No risk of bias wasindicated in only eight studies. There were insufficientstudies in any of the meta-analyses to allow us to inves-tigate for potential publication bias by preparing funnelplots.
To determine the impact of quality on outcome weundertook a sensitivity analysis for allocation conceal-ment. Four studies with low risk of bias for allocationconcealment evaluating CBT-T versus waitlist wereincluded in a sensitivity analysis. We compared theeffect size and confidence intervals from this analysiswith that of the full analysis to identify possible differ-ences. There was little differences to the estimated effectsize (N = 367, SMD −0.61 CI −1.05, −0.17) from that ofthe original analysis (N = 746, SMD −0.63 CI −0.93,−0.32). We were unable to repeat this sensitivity analy-sis for CBT-T versus supportive counselling as no studywas rated low risk of bias for allocation concealment.
4. Discussion
4.1. Main findings
There was little evidence that most multiple sessionintervention aimed at everyone, irrespective of theirsymptoms, following a traumatic event were effective.Where there was evidence of significant effects, theseeffects were judged as not being clinically importanton our primary outcome measure.
CBT-T, cognitive therapy without exposure, EMDR,structured writing therapy and internet-based guidedself-help all did significantly better than waitlist/usualcare at reducing traumatic stress symptoms in indivi-duals who were symptomatic at entry into the study.Findings for CBT-T, EMDR and cognitive therapywithout exposure were judged as clinically important.CBT-T was the most frequently evaluated approach butEMDR showed the largest effects with positive findingsfrom four small studies. Findings in relation to struc-tured writing therapy and internet-based guided self-help were from single small studies. CBT-Twas the only
18 N. P. ROBERTS ET AL.
approach to be thoroughly evaluated against an activecontrol, with evidence of significant and clinicallyimportant effects in relation to supportive counselling.Only CBT-T and cognitive therapy were evaluated forindividuals who were diagnosed with acute stress dis-order or PTSD and the magnitude of effect was largerfor these individuals. Evidence of the benefits of CBT-Tfor symptomatic individuals who did not meet fulldiagnostic criteria for these conditions was weaker.Although intervention in many of the positive trialsincluded in this review began more than a month afterthe trauma, there was evidence of the benefit of bothCBT-T and EMDR being offered within 2–4 weeksfrom a number of trials (Bryant et al., 1998, 1999,2003, 2005, 2008; Jarero et al., 2011, 2015), suggestingthat it is appropriate to offer early intervention, whenindicated within this acute phase. With the exception ofone study evaluating cognitive therapy based on theEhlers & Clarke model (Ehlers et al., 2003), the majorityof positive trials of CBT-T were based on adapted ver-sions of prolonged exposure. Several well-controlledstudies evaluated a collaborative/stepped care approachfor individuals with traumatic stress symptoms begin-ning within three months of a traumatic event. In meta-analysis there was evidence of an effect at 3–6 months;findings were not judged clinically important. TheGRADE ratings for most meta-analyses was low tovery low suggesting that further research is very likelyto have an important impact on confidence in theestimate of effect and is likely to change the estimate,for findings rated low and findings should be consid-ered uncertain for findings rated very low. There wasconsiderable variability in the timing and collection ofmedium and long-term follow-up data which made itdifficult to draw firm conclusions about the mainte-nance of effects over time. Although there was someinconsistent evidence of long-term benefit for CBT-T.
4.2. Heterogeneity
There was evidence of both clinical and statisticalheterogeneity in the included studies. There weresignificant differences in the clinical populationsacross the included studies, especially with regardsto the nature of trauma exposure and the psychiatricand physical severity of symptoms on entry into thestudies. Of note, participants in some studies hadexperienced serious and life threatening medical con-ditions associated with a chronic illness and it is likelythat intervention outcomes in these studies would beinfluenced by the degree and pace of physical recov-ery and enduring health problems (e.g. Cox et al.,2018; Irvine et al., 2011; Jensen et al., 2016; Joneset al., 2010). Studies also differed in the methodolo-gies that they used, for example with regard tosources of recruitment and inclusion and exclusioncriteria.
Although all the trials attempted to reduce trau-matic stress symptoms, the nature of the interven-tions and target populations were diverse. This waspartially dealt with by separating interventions intopredetermined groups for studies offering interven-tion to individuals with traumatic stress symptomswithin three months of a traumatic event and studiesoffering intervention to individuals with a diagnosisof acute stress disorder or PTSD, although someinterventions did not fit with these pre-plannedgroups and this resulted in some unplanned categor-izations. We attempted to group studies in a clinicallymeaningful way with regards to the intervention andthe clinical populations included but recognize thatthis is not empirically based and would have contrib-uted to heterogeneity. This should be borne in mindwhen interpreting our findings (Borenstein, Hedges,Higgins, & Rothstein, 2009). Some interventions andpopulations were so dissimilar that it was meaning-less to group them at all, particularly for studiesevaluating interventions aimed at any individual,regardless of symptoms.
As in our previous review (Roberts et al., 2009),there were more studies evaluating CBT-T than otherinterventions. Most CBT-T studies were based ona prolonged exposure paradigm, but the specificCBT-T interventions varied in their use of imaginalexposure, in-vivo exposure and cognitive techniques.Two studies were based on a cognitive processingtherapy paradigm (Nixon, 2012; Nixon et al., 2016)and showed no effect when compared against sup-portive counselling. The total number of hours ofintervention provided varied from around twohours to around 16 hours. A post hoc sub-groupanalysis suggested the effects were larger for studiesoffering more sessions of CBT-T. However, the lar-gest treatment effect that we observed was for briefEMDR which at 2–4½ hours were amongst the short-est interventions that were included.
4.3. Methodological quality
The overall quality of the studies was varied. Using theCochrane risk of bias criteria, the proportion of studiesdescribing appropriate randomization, allocation con-cealment and blinding of assessors was higher than inour previous review. It is possible that other includedstudies also used appropriate randomization and allo-cation concealment procedures but reporting of theseprocedures was sometimes limited. The proportion ofstudies with low risk for incomplete outcome data waslow (43%), suggesting that many studies had difficul-ties with retention. Pre-registration of trial protocolswas an emerging issue at the time of our previousreview and none of the studies previously includedprovided a pre-publication protocol. Only a third ofthe newly included studies provided pre-registered
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 19
study protocols and reported outcomes consistent withthese protocols. Few studies were free of other biases.These biases included author affiliation with one of theinterventions being tested, small sample size, use ofmeasures with inadequate validation, non-manualizedintervention and poor treatment adherence.
Many of the included studies had some metho-dological limitations. However, a sensitivity analysisof higher quality studies based on allocation con-cealment made little difference to the estimatedeffect of CBT-T. This suggests that study qualitydid not have a major effect in elevating apparentefficacy in this key comparison; although we couldnot undertake similar sensitivity analyses in othersmaller comparisons. There is evidence that smallerstudies can exaggerate intervention effects as theytend not to be conducted with the same methodo-logical rigour as larger trials (Higgins & Green,2011). Many of the trials in this review weresmall and this needs to be borne in mind whenconsidering the large effects of some of our find-ings. For example, the large effect in favour ofEMDR over waiting list was a result of 4 trialswith a total of 84 participants.
Four studies evaluated a collaborative/stepped careapproach (O’Donnell et al., 2012; Zatzick et al., 2004,2013, 2015). The specific collaborative care modelsdiffered across these studies, with intervention poten-tially ongoing to 12 months in some trials.Intervention effects in one smaller study (O’Donnellet al., 2012) were noticeably larger than for the otherstudies. This study differed from the other studies inthat participants were screened for elevated symp-toms on two occasions which meant that only parti-cipants who demonstrated high symptom severitywere randomized and then offered a menu of inter-ventions. The other studies allocated patients at anearlier time point and it is likely that some patientswould have experienced natural recovery. Whilsteffects across these studies was small, it has beenargued that collaborative care based approaches canhave a larger population impact than early interven-tions such as CBT-T, when intervention reach istaken into account (Giummarra et al., 2018; Zatzick,Koepsell, & Rivara, 2009).
There was only very limited reporting of adverseevents. Where adverse events were reported, thiswas mainly in trials where there was a high riskof mortality in included participants, resulting fromchronic illnesses (e.g. Irvine et al., 2011-Jones et al.,2010). We did not see evidence of significant dif-ferences in rates of dropout between interventionand control conditions, which continues to suggestthat adverse effects were not common. Despite ourprevious recommendation there was an absence oftolerability assessment, evaluating the acceptabilityof interventions, in new studies. We were unable to
investigate for publication bias. Many of the studiesreported in this review did report null results andwe enquired about non-published studies that hadregistered a study protocol. However, we cannotexclude the possibility that some of our findingsmay have been influenced by some non-reportingof negative findings.
4.4. Implications for practice
Consistent with our previous review, the currentfindings suggest that psychological interventionoffered to all individuals exposed to a traumaticevent irrespective of their symptoms cannot berecommended for routine use following traumaticevents. Several interventions – CBT-T, cognitive ther-apy without exposure, EMDR, structured writingtherapy, and internet-based guided self-help – pro-vided evidence of efficacy in reducing traumatic stresssymptoms, when targeted at symptomatic individuals.Evidence was strongest for CBT-T and for those whofulfilled the diagnostic criteria for acute stress disor-der or PTSD. We believe that this evidence is nowsufficiently strong to recommend the provision ofCBT-T, cognitive therapy or brief EMDR to indivi-duals who are symptomatic following exposure toa traumatic event, as was recommended in the recentISTSS PTSD Treatment Guidelines (InternationalSociety for Traumatic Stress Studies, 2018).However, we note that the National Institution forHealth and Care Excellence had access to the sameevidence base but only felt able to recommend CBT-T (National Institute for Health and Care Excellence,2018). We also note that positive studies were mainlythose including victims of accidental physical injury,such as industrial accidents and motor vehicle acci-dents; physical assault/violent crime; and terrorism.Only one small positive trial was undertaken follow-ing a natural disaster (Jarero et al., 2011). We did notidentify any positive studies that were carried outwith military personnel and studies conducted mainlyor solely with victims of rape and sexual assault werenot positive (Echeburua et al., 1996; Foa et al., 2006).This needs to be borne in mind when considering thegeneralizability of these findings.
Whilst no intervention aimed at all individualsexposed to a traumatic event provided clinicallyimportant findings for a reduction in traumaticsymptoms, small significant differences wereobserved for brief CBT based dyadic therapy, self-guided internet-based intervention and intensivecare diaries at 3–6 months. Given that many indivi-duals experience improvement in traumatic stresssymptoms without the need for intervention, it ispossible that that these interventions may demon-strate a greater effect if targeted at symptomatic indi-viduals. This should be examined further.
20 N. P. ROBERTS ET AL.
Findings from this review provide a strengtheningcase for early routine detection and assessment ofindividuals exposed to traumatic events and the pro-vision of early psychological intervention whenneeded, although optimal models of care requirefurther exploration. This is consistent with recentwork which suggests that early structured clinicianbased PTSD assessment using the ClinicianAdministered PTSD Scale can predict the likelihoodof developing long-term PTSD with a high degree ofaccuracy, across a number of different cultures(Shalev et al., 2019). Arguably, routine use of detec-tion-based approaches would help to reduce the inci-dence of chronic disorders and associated secondaryproblems discussed earlier (McFarlane, 2010). Self-guided (Mouthaan et al., 2013) and guided self-help(Cernvall et al., 2015) potentially offer a flexible andcost-effective means of increasing availability of inter-vention and should be investigated further.
This review did not focus on the use of pharma-cological early interventions. Other work that wehave undertaken for the ISTSS TreatmentGuidelines suggests that the evidence for such inter-ventions is currently very limited (Astill-Wright et al.,in press; International Society for Traumatic StressStudies, 2018). However, we recognize that medica-tion may still have a role in holistic patient care, whenindicated, following trauma exposure.
4.5. Implications for research
Several interventions included in this review showedpromising outcomes but have not been thoroughlyevaluated in well-designed RCTs, with long-termfollow-up. EMDR, cognitive therapy and structuredwriting therapy all require further evaluation andmay benefit from head to head comparison withan evaluated CBT-T based intervention. A numberof other interventions included in this review, suchas behavioural activation (Wagner et al., 2007), havealso not been adequately investigated and wouldbenefit from further investigation. Optimal lengthof early intervention should also be exploredfurther, given our finding that effects were largerfor 12 or more sessions of CBT-T. Future reviewsshould consider whether the literature is sufficientlydeveloped to evaluate CBT-T based interventions bytreatment model. New technologies have the poten-tial to increase the range of options and modes ofdelivery of early psychological interventions. Weincluded several studies investigating theseapproaches in this review (e.g. Ben-Zion et al.,2018; Freedman, n.d.). Development and evaluationof these approaches are in their infancy but theypotentially offer new ways of preventing and ameli-orating early symptoms. A further limitation of thisreview is that we only focused on the prevention
and early treatment of PTSD. Future studies andreviews should also focus on the prevention ofother common mental health problems such asdepression and anxiety disorders following fromtrauma.
Acknowledgements
We wish to express our thanks to authors of studies in thereview for providing unpublished data, the CochraneCommon Mental Disorders Group for his help withsearches and with translation and the InternationalSociety for Traumatic Stress Studies Treatment GuidelineCommittee for help with the methodological framework.Neil Roberts had full access to all of the data in the studyand takes responsibility for the integrity of the data and theaccuracy of the data analysis.
Disclosure statement
Jonathan Bisson has published one RCT that was included inthe review. The other authors report no competing interests.Neil Roberts, Neil Kitchiner, Catrin Lewis and JonathanBisson have all been involved in the development of aninternet based guided self-help intervention for PTSD calledSPRING and may receive future profits if the intervention ismonetized.
Funding
This study was not directly funded but was undertaken asa contribution to the International Society for TraumaticStress Studies PTSD Treatment Guidelines (ISTSS) (2018).The ISTSS provided some funding to Neil Roberts, CatrinLewis and Jonathan Bisson to attend academic meetingsduring the Guideline development process.
ORCID
Neil P. Roberts http://orcid.org/0000-0002-6277-0102Neil J. Kitchiner http://orcid.org/0000-0003-0499-9520Justin Kenardy http://orcid.org/0000-0001-9475-8450Catrin E. Lewis http://orcid.org/0000-0002-3818-9377Jonathan I. Bisson http://orcid.org/0000-0001-5170-1243
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