REVIEW ARTICLE

B R I T I S H J O U R N A L O F P S YC H I AT RY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4 . d o i : 1 0 . 11 9 2 / b j p . b p . 1 0 6 . 0 2 1 4 0 2

AUTHORS PROOF
Psychological treatments for chronic
post-traumatic stress disorder
Systematic review and meta-analysis
JONATHAN I. BISSON, ANKE EHLERS, ROSA MAT THE WS,
STEPHEN PILLING, DAVID RICHARDS and STUART TURNER

Background The relative efficacy of

different psychological treatments for
chronic post-traumatic stress disorder
(PTSD) is unclear.
Aims To determine the efficacy of
specific psychological treatments for
chronic PTSD.
Method In a systematic review of
randomised controlled trials, eligible
studies were assessed against
methodological quality criteria and data
were extracted and analysed.
Results Thirty-eight randomised
controlled trials were included in the
meta-analysis.T
meta-analysis.Trauma-focused
rauma-focused cognitive ^
behavioural therapy (TFCBT), eye
movement desensitisation and
reprocessing (EMDR), stress management
and group cognitive ^ behavioural therapy
improved PTSD symptoms more than
waiting-list or usual care.There was
inconclusive evidence regarding other
therapies.There was no evidence of a
difference in efficacy betweenTFCBTand
EMDR butthere was some evidence that
TFCBTand EMDR were superior to stress
management and other therapies, and
that stress management was superior to
other therapies.
Conclusions The first-line
psychological treatment for PTSD should
be trauma-focused (TFCBTor EMDR).
Declaration of interest

None.

Chronic post-traumatic stress disorder

(PTSD) is a common disorder that people
may develop after exceptionally threatening
and distressing events. Psychological treatments from various theoretical perspectives
have been found to be effective for chronic
PTSD in previous reviews (Van Etten &
Taylor, 1988; Bradley et al,
al, 2005). Some of
the earlier reviews had to rely on uncontrolled trials as well as controlled ones,
and on uncontrolled effect sizes. There are
now sufficient numbers of randomised controlled trials of psychological treatments of
chronic PTSD to allow a meta-analysis of effect sizes in such trials. We present a comprehensive systematic review and meta-analysis
of randomised controlled trials assessing the
efficacy of psychological treatments in reducing symptoms of chronic PTSD, and comparing the efficacy of different types of
psychological treatment in reducing symptoms of this disorder.

METHOD
This review and meta-analysis derive from
work undertaken in the preparation of
PTSD treatment guidelines for the National
Institute for Health and Clinical Excellence
(NICE) in the UK (National Collaborating
Centre for Mental Health, 2005). Further
details of the protocol are published within
the full guideline.
A systematic bibliographic search was
undertaken to find randomised controlled
trials of psychological treatments for PTSD
from databases (EMBASE, Medline,
PsycINFO and CINAHL) and the Cochrane
Library, with each database being searched
from inception to August 2004. Additional
papers were found by hand-searching the
references of retrieved articles, previous
systematic reviews and meta-analyses of psychological treatments for PTSD. The search
was restricted to papers with Englishlanguage abstracts. In addition, data from
unpublished studies or papers in press were
sought by contacting experts within the field.

Selection
Studies were only considered if PTSD
symptoms were the main target of treatment, all participants had had PTSD symptoms for at least 3 months following a
traumatic event, at least 70% of participants had a diagnosis of PTSD, and PTSD
symptoms were measured using a recognised scale. To be included studies had to
be of randomised controlled design, with
adult (4
(416 years old) participants; the
studies had to report at least pre-treatment
and post-treatment measures, and retain at
least 50% of the original sample at the
post-treatment assessment. There was no
restriction regarding type of traumatic
event. The minimum duration of symptoms
was 1 month. Early intervention trials that
only included participants with recent onset
of PTSD were not included and are considered in a separate review (further details
available from the author upon request).
The searching and selection were done by
a team of systematic reviewers led by
R.M. Any disagreements with regard to inclusion or exclusion of a study were resolved by discussion with the other authors.

Validity assessment
All published and unpublished papers were
assessed against the following quality
criteria: random sequence generation,
concealment of allocation, masked assessment of outcomes, number of withdrawals,
tolerability, adequate reporting of data and
intention-to-treat analysis.

Data abstraction
Study details including the nature of the
traumatic events, participants characteristics and type of intervention were entered
into a Microsoft Access database (version
2000), the quality criteria were applied
and outcome data for included studies were
entered into Review Manager version 4.2.3
for Windows. The application of quality
criteria and the accuracy of outcome data
were double-checked by a second reviewer.

Study characteristics
An initial narrative synthesis was undertaken
to describe the scope (participants, settings,
intervention type, comparators, measures of
effect), quality and outcomes of the studies.
Three main efficacy outcomes were considered: one dichotomous outcome (retaining a
diagnosis of PTSD) and two continuous outcomes (assessor-rated and self-reported severity of PTSD symptoms). Among the main

97

B I S S ON E T A L

AUTHORS PROOF
outcomes, the primary outcome was clinician-rated severity of PTSD symptoms,
although this was not present for all studies.

Quantitative data synthesis

Where possible, meta-analysis was used to
synthesise data, including additional metaanalyses for anxiety and depression measures where available, and numbers leaving
the study early, using Review Manager.
Post-treatment data (or change scores if
reported instead of post-treatment data)
for the psychological treatment and control
condition were entered in the Review
Manager tables. Dichotomous outcomes
(PTSD diagnosis and leaving the study early
for any reason) were analysed as a relative
risk number and were calculated on an
intention-to-treat basis (i.e. a once randomised always analyse basis). This makes
the conservative assumption that all participants who ceased to engage in the study
had an unfavourable outcome, e.g. they left
because the treatment was not acceptable
and still had a diagnosis of PTSD. Continuous outcomes were analysed as standardised
mean differences (SMDs) to allow for ease of
comparison across studies. It was not possible to obtain intention-to-treat data for most
of the trials, and we therefore used completer
data for all continuous outcomes.
For consistency of presentation all data
were entered into Review Manager in such
a way that negative effect sizes or relative risk
numbers less than 1 represented an effect that
favoured the active treatment compared with
the waiting-list control. Data were pooled
from more than one study using a fixedeffects meta-analysis except where heterogeneity was present, in which case a randomeffects model was used as described below.

In the random-effects analysis, heterogeneity

is accounted for both in the width of confidence intervals and in the estimate of the
treatment effect. With decreasing heterogeneity the random-effects approach moves
asymptotically towards a fixed-effects model.
An I2 of 3050% was taken to indicate moderate heterogeneity. In this case, both the w2test of heterogeneity and a visual inspection
of the forest plot were used to decide between
a fixed- and random-effects model.
In order to explore heterogeneity
further, sensitivity analyses were performed
to consider the influence of higher-quality
methodology (this was done by considering
studies that used masked assessment, and
those that used an intention-to-treat analysis), studies that only included females and
those that only included Vietnam veterans.

Clinical effectiveness
Where psychological interventions were
compared against waiting-list control
groups an effect size (SMD) of 70.8 or less
(e.g. a larger negative number) was considered clinically meaningful for continuous
variables (a large effect size; Cohen,
1988) and for dichotomous outcomes a relative risk of 0.65 or less (or greater than
1.54) was considered clinically meaningful.
Where two active treatments were compared lower thresholds were set with an
SMD of 70.5 or +0.5 for continuous
variables (a medium effect size), and for
dichotomous outcomes a relative risk of
0.80 or less or 1.25 or greater was considered clinically meaningful. These thresholds

came from discussions in the NICE Guideline Development Group in advance of

undertaking the meta-analyses and were
based on clinical experience and thresholds
used in the literature (Schnurr et al,
al, 2003).
In order to be considered clinically meaningful the value had to meet the threshold
criterion and the 95% confidence interval
had to be greater than the threshold. If
the SMD and relative risk met the threshold
criterion but the 95% CI included values in
the non-clinically significant range, this was
interpreted as limited evidence for an effect.
Similarly, if the SMD or relative risk value
was below the threshold, the 95% CIs were
examined to determine whether the evidence
was inconclusive (in case the 95% CI included numbers greater than the threshold)
or whether it could be stated that there was
evidence suggesting that an effect was
unlikely (where the 95% CI was entirely
outside the clinically meaningful range).

Psychological treatment categories

Five separate psychological treatment categories were defined (see Appendix). These
came from discussions by the NICE Guideline Development Group in advance of
undertaking the meta-analyses and were
based on clinical experience and categories
used in the literature (Foa et al,
al, 2000).

RESULTS
Thirty-eight studies were included in the
meta-analysis. Figure 1 shows the metaanalysis profile summarising trial flow.

Heterogeneity
To check for heterogeneity between studies,
both the I2-test of heterogeneity and the w2test of heterogeneity (P
(P50.10) as well as
visual inspection of the forest plots were used.
The I2 statistic describes the proportion of total variation in study estimates that is due to
heterogeneity (Higgins & Thompson, 2002).
An I2 of less than 30% was taken to indicate
mild heterogeneity and a fixed-effects model
was used to synthesise the results. An I2 of
more than 50% was taken as notable heterogeneity; in this case an attempt was made to
explain the variation. If studies with heterogeneous results were found to be comparable,
a random-effects model was used to summarise the results (DerSimonian & Laird, 1986).

98

Fig. 1 Trial flow (PTSD, post-traumatic stress disorder; RCT, randomised controlled trial).

7 studies
n267
267
RR1.14
RR 1.14
(95% CI 0.70 to 1.85)

6 studies

n187
187

SMD0.02
SMD 0.02

(95% CI 70.5 to 0.55)

(95% CI 0.31 to 1.01)

(95% CI 71.14 to 70.31)

?

RR0.56
RR 0.56

SMD7
SMD 70.72

(ET)
(E T)

n48
48

n97
97

EMDR v.TFCBT

1 study

1 study

list/usual care

(95% CI 70.98 to 70.24)

Group CBT v. waiting

(95% CI 70.48 to 0.20)

SMD7
SMD 70.14

SMD7
SMD 70.17
(95% CI 70.45 to 0.11)

n136
136

4 studies

(ET)
(E T)

No data

(95% CI 70.82 to 70.14)

SMD7
SMD 70.48

n153
153

n206
206

7 studies

(ET)
(E T)

(95% CI 71.2 to 70.22)

SMD7
SMD 70.71

n71
71

2 studies

SMD7
SMD 70.61

n132
132

2 studies

(GC4
(GC4W)

(O4
(O4W)

(O4
(O4W)
3 studies

(95% CI 71.23 to 70.31)

SMD7
SMD 70.77

n82
82

3 studies

(95% CI 71.54 to 70.85)

SMD7
SMD 71.20

n156
156

5 studies

E4W

(95% CI 71.20 to 70.78)

SMD7
SMD 70.99

n415
415

11 studies

(T4
(T4W)

Anxiety

(95% CI 70.47 to 1.14)

SMD0.33
SMD 0.33

(95% CI 0.53 to 1.18)

(95% CI 0.47 to 0.87)

(95% CI 71.62 to 70.67)

(95% CI 70.9 to 0.04)

RR0.64
RR 0.64

SMD7
SMD 71.14

n24
24

RR0.79
RR 0.79

n121
121

n86
86

usual care

1 study

SMD7
SMD 70.43

4 studies

3 studies

v. waiting list/

n166
166

(S4
(S4W)

(S4
(S4W)

Stress management

(95% CI 72.13 to 70.13)

SMD7
SMD 71.13

n72
72

(95% CI 0.28 to 0.86)

(95% CI 71.87 to 71.15)

3 studies

RR0.49
RR 0.49

SMD7
SMD 71.51

n156
156

2 studies

n217
217

n162
162

5 studies

(E4
(E4W)

waiting list/usual care

6 studies

5 studies

list/usual care

(E4
(E4W)

E4W

EMDR v. waiting

(95% CI 72.17 to 71.24)

(95% CI 0.35 to 0.57)

(95% CI 71.89 to 70.91)

SMD7
SMD 71.70

n428
428

9 studies

T4W

Self-rated PTSD symptoms

Other therapies v.

n763
763

15 studies

14 studies

list/usual care
RR0.44
RR 0.44

T4W

T4W

TFCBT v. waiting

SMD7
SMD 71.40

(intent-to-treat)

PTSD symptoms

n649
649

PTSD diagnosis

Clinician-rated

Comparison

Table
Table 1 Summary of meta-analysis of comparisons of psychological treatments v. waiting list conditions

(95% CI 70.9 to 0.26)

SMD7
SMD 70.32

n206
206

7 studies

No data

(95% CI 70.71 to 0.22)

SMD7
SMD 70.25

n72
72

2 studies

(95% CI 71.12 to 70.33)

SMD7
SMD 70.73

n109
109

4 studies

(95% CI 71.84 to ^1.12)

SMD7
SMD 71.48

n160
160

5 studies

E4W

(95% CI 71.69 to 70.82)

SMD7
SMD 71.26

n625
625

14 studies

T4W

Depression

(Continued)
Continued)

(95% CI 0.58 to 1.30)

RR0.87
RR 0.87

n287
287

8 studies

(95% CI 0.64 to 1.56)

RR1.00
RR 1.00

n271
271

3 studies

(95% CI 1.19 to 12.29)

RR3.82
RR 3.82

n166
166

3 studies

(W4
(W4O)

(95% CI 0.71 to 6.73)

6.73)

RR2.19
RR 2.19

n121
121

4 studies

(95% CI 0.66 to 2.22)

RR1.21
RR 1.21

n216
216

6 studies

(95% CI 1.05 to 1.94)

RR1.42
RR 1.42

n861
861

15 studies

(W4
(W4T)

Withdrawal rate

T R E AT M E N T OF C H R
RONI
ONI C P T S D

AUTHORS PROOF

99

10 0

(Continued)
Continued )

(intent-to-treat)

PTSD symptoms

(95% CI 72.32 to 70.03)

?

n284
284
RR0.78
RR 0.78
(95% CI 0.61 to 0.99)
(T4
(T4O)
5 studies
n286
286
RR0.71
RR 0.71
(95% CI 0.56 to 0.89)
(E4
(E4S)

6 studies

n239
239

SMD7
SMD 70.27

(95% CI 70.71 to 0.16)

(T4
(T4O)

3 studies

n120
120

SMD7
SMD 70.81

(95% CI 71.19 to 70.42)

TFCBT v. other

therapies

(T4
(T4O)

(95% CI 0.46 to 1.04)

(E4
(E4O)

SMD7
SMD 70.35

(95% CI 70.90 to 0.19)

n360
360
RR0.98
RR 0.98
(95% CI 0.83 to 1.16)

n325
325

SMD7
SMD 70.12

(95% CI 70.34 to 0.1)

(non-trauma-focused)

No data

No data

(95% CI 71.32 to 0.29)

SMD7
SMD 70.51

n25
25

1 study

No data

(95% CI 71.31 to 0.30)

RR7
RR 70.51

n25
25

1 study

(95% CI 71.03 to 70.32)

SMD7
SMD 70.67

n127
127

2 studies

(T4
(T4O)

(95% CI 71.14 to 70.20)

SMD7
SMD 70.67

n75
75

3 studies

(E4
(E4S)

(95% CI 71.03 to 70.28)

SMD7
SMD 70.65

n120
120

3 studies

(T4
(T4O)

(95% CI 70.57 to 0.08)

SMD7
SMD 70.25

n161
161

5 studies

Depression

(95% CI 1.00 to 1.90)

RR1.38
RR 1.38

n360
360

1 study

(GC4
(GC4GT)

(95% CI 0.2 to 3.46)

RR0.82
RR 0.82

n31
31

1 study

(95% CI 0.26 to 8.54)

RR1.48
RR 1.48

n127
127

2 studies

(O4
(O4T)

(95% CI 0.37 to 2.88)

RR1.03
RR 1.03

n84
84

3 studies

(95% CI 0.68 to 1.90)

RR1.14
RR 1.14

n290
290

5 studies

(95% CI 0.69 to 2.0)

RR1.17
RR 1.17

n284
284

6 studies

Withdrawal rate

1. Key to comparison: X4Y, evidence that X has clinically important advantages over Y; (X
(X4Y ), limited evidence that X has clinically important advantages over Y; ?, evidence is inconclusive so it is not possible to determine whether there is a
clinically important difference; (X
(XY
Y ), there is evidence suggesting that there is unlikely to be a clinically important difference.
CBT, cognitive ^behavioural therapy; EMDR, eye movement desensitisation and reprocessing; GC, group CBT, non-trauma-focused; GT, groupTFCBT; O, other therapies; PTSD, post-traumatic stress disorder; RR, relative risk; S, stress
management; SMD, standardised mean difference; TFCBT, trauma-focused CBT; W, waiting list/usual care.

1 study

1 study

v. group CBT

(95% CI 0.30 to 1.11)

(95% CI 72.09 to 70.35)

(GTGC)
(GT GC)

RR0.58
RR 0.58

SMD7
SMD 71.22

(GTGC)
(GT GC)

n31
31

n25
25

Group TFCBT

1 study

1 study

v. other therapies

No data

(95% CI 71.08 to 70.36)

(95% CI 71.21 to 70.47)

(95% CI 0.19 to 0.84)

?

SMD7
SMD 70.72

SMD7
SMD 70.84

RR0.4
RR 0.4

(S4
(S4O)

n126
126

n124
124

n67
67

2 studies

(T4
(T4O)

(95% CI 71.36 to 70.13)

SMD7
SMD 70.75

n45
45

2 studies

SMD7
SMD 70.40

n75
75

2 studies

(E4
(E4S)

(95% CI 71.11 to 0.17)

SMD7
SMD 70.47

n197
197

4 studies

(95% CI 70.49 to 0.26)

SMD7
SMD 70.12

n127
127

4 studies

(TS)
(T S)

Anxiety

1 study

Stress management

therapies

No data

RR0.69
RR 0.69

n53
53

EMDR v. other

(95% CI 70.86 to 0.06)

n84
84

2 studies

management
3 studies

3 studies

EMDR v. stress

SMD7
SMD 71.18

n176
176

3 studies

(T4
(T4O)

(95% CI 70.74 to 0.01)

SMD7
SMD 70.37

n127
127

3 studies

6 studies

?
?

Self-rated PTSD symptoms

management

(T4
(T4S)

PTSD diagnosis

Clinician-rated

TFCBT v. stress

Comparison

T
Table
able 1

B I S S ON E T A L

AUTHORS PROOF

T R E AT M E N T OF C H R
RONI
ONI C P T S D

AUTHORS PROOF
Study characteristics
Details of the studies included appear in the
data supplement to the online version of
this article. Twenty-five studies compared
trauma-focused
cognitivebehavioural
therapy (TFCBT) with waiting-list or other
psychological interventions: Blanchard et al
(2003), Brom et al (1989), Bryant et al
(2003), Cloitre et al (2002), Cooper &
Clum (1989), Devilly & Spence (1999),
Echeburua et al (1997), Ehlers et al
(2005), Fecteau & Nicki (1999), Foa et al
(1991, 1999), Gersons et al (2000), Ironson
et al (2002), Keane et al (1989), Kubany et
al (2003), Kubany et al (2004), Lee et al
(2002), Marks et al (1998), Paunovic &
Ost (2001), Peniston & Kulkosky (1991),
Power et al (2002), Resick et al (2002),
Rothbaum et al (2005), Taylor et al
(2003) and Vaughan et al (1994). Twelve
studies compared eye movement desensitisation and reprocessing (EMDR) with
waiting-list or other psychological interventions: Carlson et al (1998), Devilly &
Spence (1999), Ironson et al (2002), Jensen
(1994), Lee et al (2002), Marcus et al
(1997), Power et al (2002), Rothbaum
(1997), Rothbaum et al (2005), Scheck et
al (1998), Taylor et al (2003) and Vaughan
et al (1994). Seven studies compared stress
management with waiting-list or other
psychological interventions: Carlson et al
(1998), Echeburua et al (1997), Foa et al
(1991, 1999), Marks et al (1998), Taylor
et al (2003) and Vaughan et al (1994). Six
studies compared other therapies with
waiting-list or other psychological interventions: Blanchard et al (2003), Brom et
al (1989), Bryant et al (2003), Foa et al
(1991), Marcus et al (1997) and Scheck
et al (1998). Four studies compared group
cognitivebehavioural
therapy
with
waiting-list or other psychological interventions: Classen et al (2001), Krakow et
al (2001), Schnurr et al (2003) and Zlotnick
et al (1997).
Two additional randomised controlled
trials met inclusion criteria but differed in
mode of delivery (Lange et al,
al, 2003; Neuner
et al,
al, 2004), and one further trial compared
two versions of TFCBT (exposure and
cognitive therapy) with each other (Tarrier
et al,
al, 1999a
1999a,b). These studies could not be
included in the meta-analysis.

Quantitative data synthesis

Table 1 provides details of the quantitative
data synthesis. It highlights that TFCBT
and EMDR were better than waiting-list/

control on most outcome measures. Stress

management was better on some outcomes,
and other therapies appeared to be the
least effective. Unfortunately none of the
studies reported adverse effects and
therefore it was not possible to analyse
these. However, most studies did report
withdrawal rates and these are included in
Table 1.

Sensitivity analyses
Masked assessment
The EMDR studies using masked assessment showed evidence favouring EMDR
over waiting-list on reducing the severity
of PTSD symptoms (clinician-rated measures) (three studies, n120;
120; SMD7
SMD 71.54,
1.54, 95% CI 71.95 to 71.12) similar to
that in all EMDR studies (see Table 1).
The TFCBT studies using masked assessment showed evidence favouring TFCBT
over waiting-list on reducing the severity of
PTSD symptoms (clinician-rated
(clinician-rated measures)
(seven studies, n308;
308; SMD7
SMD 71.70; 95%
CI 72.47 to 70.93) similar to that in all
TFCBT studies.

Vietnam veteran studies

One EMDR study considered only Vietnam
veterans. This showed less evidence
favouring EMDR over waiting-list on
reducing the severity of PTSD symptoms
(clinician-rated measures) (one study,
n25;
25; SMD7
SMD 70.97, 95% CI 71.81 to
70.13) than the other EMDR studies (see
Table 1). One TFCBT study considered
only Vietnam veterans using the primary
outcome measure; this showed less evidence
favouring TFCBT over waiting-list on reducing the severity of PTSD symptoms (clinician-rated measures) (one study, n24;
24;
SMD7
SMD 70.22, 95% CI 71.03 to 0.58)
than the other TFCBT studies.

Female studies
The EMDR studies including only female
participants showed evidence favouring
EMDR over waiting-list on reducing the
severity of PTSD symptoms (clinician-rated
measures) (two studies, n57;
57; SMD
SMD
71.67, 95% CI 72.30 to 71.04) similar
to that in all EMDR studies. The TFCBT
studies including only female participants
showed more evidence favouring TFCBT
over waiting-list on reducing the severity
of PTSD symptoms (clinician-rated measures) (six studies, n358;
358; SMD7
SMD 72.06,

95% CI 72.70 to 71.42) than all TFCBT

studies.

Intention-to-treat analysis
None of the EMDR studies reported using
an intention-to-treat analysis so this could
not be assessed. The TFCBT studies using
an intention-to-treat analysis showed more
evidence favouring TFCBT over waiting-list
on reducing the severity of PTSD symptoms
(clinician-rated measures) (six studies,
n332;
332; SMD7
SMD 71.82, 95% CI 72.76 to
70.89) than all TFCBT studies.

DISCUSSION
We identified 38 randomised controlled
trials of psychological treatments for PTSD.
Trauma-focused
cognitivebehavioural
therapy showed clinically important benefits over waiting-list or usual care on all
measures of PTSD symptoms. In addition,
there was limited evidence that it also has
clinically important effects on depression
and anxiety. The effectiveness of eye movement desensitisation and reprocessing
was also generally supported by the metaanalysis, but the evidence base was not as
strong as that for TFCBT, both in terms
of the number of trials available and the
certainty with which clinical benefit was established. Furthermore, there was limited
evidence that TFCBT and EMDR were
superior to supportive/non-directive treatments, hence it is highly unlikely that their
effectiveness is due to non-specific factors
such as attention. There was limited evidence for stress management and group
cognitivebehavioural
cognitivebehavioural therapy, but other
therapy (supportive/non-directive therapy,
psychodynamic therapies and hypnotherapies) that focused on current or past
aspects of the patients life other than the
trauma or on general support did not show
clinically important effects on PTSD symptoms, depression or anxiety. However, this
might be due to the limited number of
studies available and does not mean
that these treatments were shown to be
ineffective.
The treatments most supported by the
review (individually delivered TFCBT and
EMDR) are both trauma-focused psychological treatments that specifically address
the patients troubling memories of the
traumatic event and the personal meanings
of the event and its consequences. Direct
comparisons of these two approaches did
not reveal any significant advantages of

101

B I S S ON E T A L

AUTHORS PROOF
one over the other, with respect to either
treatment outcome or speed of therapeutic
change (Taylor et al,
al, 2003).

Heterogeneity
There is clearly considerable clinical
diversity within the studies considered.
The separation of different active interventions into groups partially addresses
their impact on clinical diversity, but not
all trials within the same group used identical interventions. The differences were
most marked in the other therapy group,
which had in common the absence of
cognitivebehavioural
techniques
and
trauma-focused work. There was also
diversity in the TFCBT group, which
included both exposure-only and traumafocused cognitive therapy interventions.
Another source of heterogeneity was
the quality of the studies. Sensitivity
analyses of higher-quality and lowerquality studies were performed to explore
this further. There was some limited
evidence that higher-quality studies (those
including masked assessment of outcome
or intention-to-treat analysis) showed
better outcomes than the lower-quality
studies. This finding contradicts previous
research (Moher et al,
al, 1998) that has found
an association between poorer methodology and more favourable results for the
intervention. It may reflect the fact that
the better studies tended to be more recent
and associated with refinement of techniques. They also included most of the
female-only studies. The fact that femaleonly studies showed a better response to
TFCBT than mixed studies and male-only
studies is difficult to interpret. It may be
that the female-only studies used more
effective interventions, that the trauma of
rape is more amenable than other traumas
to effective TFCBT, or that for some undetermined reason women are more responsive to TFCBT than men. Interestingly, a
similar superiority in female response has
been found for pharmacological treatment
of PTSD (National Collaborating Centre
for Mental Health, 2005). The finding that
studies including only Vietnam veterans
produced worse responses to TFCBT and
EMDR might have contributed to the
female studies finding and also suggests
that Vietnam veterans are a particularly
difficult population to treat.
As with all psychological treatment
trials, there are issues with the control
group. The development of a psychological

10 2

treatment placebo is difficult, if not impossible, as is masking of participants and

therapists. In several of the waiting-list or
usual care conditions it was apparent that
some (usually poorly defined) treatment
was going on. The main effect of this is
likely to have made it more difficult for
the active intervention to show itself to be
superior to the control condition.

Tolerability
Unfortunately none of the studies reported
adverse effects. It remains unclear whether
no adverse effects occurred, or whether
they were not described. This is a key shortcoming in the trials identified. Most studies
reported withdrawals by group. There are
likely to be several different factors that
determine withdrawal rates, including the
tolerability of the intervention. There was
limited evidence that TFCBT and other
therapies fared worse than waiting-list or
usual care on this outcome measure, but
there was no significant difference in withdrawal rates in direct comparisons between
any of the active treatments. The higherquality TFCBT studies showed no difference in withdrawal rates when compared
with waiting-list or usual care. Some people
find it difficult to fully engage in psychological treatment because it requires a
significant commitment of time and emotion. For some people with PTSD it may
initially be difficult and overwhelming to
disclose details of their traumatic events.
It is also well recognised that some patients
may be subject to initial adverse effects
such as increased re-experiencing following
exposure treatment (Pitman et al,
al, 1991; Foa
et al,
al, 2002; Hackmann et al,
al, 2004). Withdrawal rates of up to 30% in some studies
suggest that the active treatments were not
always acceptable to those receiving them.
It is possible that in these cases devoting
several sessions to establishing a trusting
therapeutic relationship and emotional stabilisation, before addressing the traumatic
event, might lead to greater acceptability.

Limitations of the meta-analysis

Although this meta-analysis provides a
systematic and comprehensive comparison
of the different psychological treatments
of PTSD, it is not without methodological
problems. The randomised controlled trials
analysed usually reported unadjusted
means for the treatment conditions after
therapy and at follow-up.
follow-up. Sample sizes
were usually small, raising the chance that

baseline differences present before treatment influenced scores after treatment.

Indeed, some studies showed baseline
differences between the study conditions
that remained uncorrected in our analysis.
However, across studies no systematic
baseline difference existed, so the conclusions remain valid. Furthermore, the Review Manager program does not allow
entering a score of 0 for both groups. Thus,
the withdrawal rates reported are slight
overestimates of the true rates.

Clinical implications
Our results suggest that trauma-focused
psychological treatments (TFCBT or
EMDR) are effective for chronic PTSD.
Indeed, the effect sizes compare favourably
with those found for cognitivebehavioural
therapy in depressive and anxiety disorders
(National Collaborating Centre for Mental
Health, 2004; National Collaborating
Centre for Primary Care, 2004). These
treatments are normally delivered on an
individual out-patient basis over 812
sessions. A course of trauma-focused
psychological treatment should be offered
to everyone with chronic PTSD. The results
also suggest that not all chronic PTSD will
benefit from these treatments; other
approaches should then be considered,
including extending the number of sessions,
trying an alternative form of traumafocused psychological treatment and the
augmentation of trauma-focused psychological treatment with a course of pharmacological treatment. A recent meta-analysis
has suggested that pharmacological
interventions are unlikely to be as clinically
effective as trauma-focused psychological
interventions and should therefore be used
as a second-line treatment (National
Collaborating Centre for Mental Health,
2005).

Future research
Further well-designed trials of psychological treatments are required, including
further comparison studies of one type of
psychological treatment against another.
There is a need for large-scale studies
(phase 4) to find out whether the results
will survive in real practice. Future trials
should consider adverse events and tolerability of treatment in more detail. Our results suggest that several of the currently
available treatments might benefit from
modifications that would make them more
acceptable to people with chronic PTSD

T R E AT M E N T OF C H R
RONI
ONI C P T S D

AUTHORS PROOF
and possibly also more effective. There is
also potential for research concerning the
direct comparison of psychological treatments with pharmacological treatments,
the effectiveness of a combination of the
two, and the implications of the high degree
of comorbidity with other disorders for the
choice of treatment.

APPENDIX
Psychological treatment categories
Treatments delivered on an individual basis
that focused on the memory for the traumatic
event and its meaning
1. Trauma-focused
Trauma-focused cognitive ^ behavioural therapy
(TFCBT).
2. Eye movement desensitisation and reprocessing
(EMDR).

Treatments delivered on an individual basis

that do not place the main focus of treatment
on the trauma
3. Stress management and relaxation.
4. Other therapies (including supportive therapy/
non-directive counselling, psychodynamic therapies
and hypnotherapy).

Cohen, J. (1988) Statistical Power Analysis for the

Behavioral Sciences.
Sciences. Erlbaum.

disorder: a randomized controlled trial. JAMA,

JAMA, 286,
286,
537^545.

*Cooper, N. A. & Clum, G. A. (1989) Imaginal flooding

as a supplementary treatment for PTSD in combat
veterans: a controlled study. Behavior Therapy,
Therapy, 20,
20,
381^391.

*Kubany, E. S., Hill, E. E. & Owens, J. A. (2003)

DerSimonian, R. & Laird, N. (1986) Meta-analysis in

clinical trials. Controlled Clinical Trials,
Trials, 7, 177^188.
*Devilly, G. J. & Spence, S. H. (1999) The relative
efficacy and treatment distress of EMDR and a
cognitive ^ behaviour trauma treatment protocol in the
amelioration of posttraumatic stress disorder. Journal of
Anxiety Disorders,
Disorders, 13,
13, 131^157.
*Echeburua, E., de Corral, P., Zubizarreta, I., et al
(1997) Psychological treatment of chronic posttraumatic

stress disorder in victims of sexual aggression. Behavior

Modification,
Modification, 21,
21, 433^56.
*Ehlers, A., Clark, D., Hackmann, A., et al (2005)

Cognitive therapy for posttraumatic stress disorder:

development and evaluation. Behaviour Research and
Therapy,
Therapy, 43,
43, 413^431.
*Fecteau, G. & Nicki, R. (1999) Cognitive behavioural
treatment of post traumatic stress disorder after motor
vehicle accident. Behavioural and Cognitive Psychotherapy,
Psychotherapy,
27,
27, 201^214.
*Foa, E. B., Rothbaum, B. O., Riggs, D. S., et al (1991)

Treatment of posttraumatic stress disorder in rape

victims: a comparison between cognitive ^ behavioral
procedures and counseling. Journal of Consulting and
Clinical Psychology,
Psychology, 59,
59, 715^723.
*Foa, E. B., Dancu, C.V., Hembree, E. A., et al (1999)

Treatments delivered in groups

5. Group cognitive ^ behavioural therapy.

REFERENCES
*Blanchard, E. B., Hickling, E. J., Devineni, T., et al
(2003) A controlled evaluation of cognitive behavioural

therapy for posttraumatic stress in motor vehicle

accident survivors. Behaviour Research and Therapy,
Therapy, 41,
41,
79^96.
Bradley, R., Greene, J., Russ, E., et al (2005) A
multidimensional meta-analysis of psychotherapy for
PTSD. American Journal of Psychiatry,
Psychiatry, 162,
162, 214^227.
*Brom, D., Kleber, R. J. & Defares, P. B. (1989) Brief
psychotherapy for posttraumatic stress disorders.
Journal of Consulting and Clinical Psychology,
Psychology, 57,
57, 607^612.
*Bryant, R. A., Moulds, M. L., Guthrie, R. M., et al
(2003) Imaginal exposure alone and imaginal exposure

with cognitive restructuring in treatment of

posttraumatic stress disorder. Journal of Consulting and
Clinical Psychology,
Psychology, 71,
71, 706^712.
*Carlson, J., Chemtob, C. M., Rusnak, K., et al (1998)

Eye movement desensitization and reprocessing

(EMDR): treatment for combat-related post-traumatic
stress disorder. Journal of Traumatic Stress,
Stress, 11,
11, 3^24.
*Classen, C., Butler, L. D., Koopman, C., et al (2001)

Supportive ^ expressive group therapy and distress in

patients with metastatic breast cancer. A randomised
clinical intervention trial. Archives of General Psychiatry,
Psychiatry,
58,
58, 494^501.
*Cloitre, M., Koenen, K. C., Cohen, L. R., et al (2002)

Skills training in affective and interpersonal regulation

followed by exposure: a phase-based treatment for
PTSD related to childhood abuse. Journal of Consulting
and Clinical Psychology,
Psychology, 70,
70, 1067^1074.

A comparison of exposure therapy, stress inoculation

training, and their combination in reducing
posttraumatic stress disorder in female assault victims.
Journal of Consulting and Clinical Psychology,
Psychology, 67,
67, 194^200.
Foa, E. B., Keane, T. & Friedman, M. (2000) Effective
Treatments for PTSD: Practice Guidelines from the
International Society for Traumatic Stress Studies.Guilford.
Studies. Guilford.
Foa, E. B., Zoellner, L. A., Feeny, N. C., et al (2002)

Does imaginal exposure exacerbate PTSD symptoms?

Journal of Consulting and Clinical Psychology,
Psychology, 70,
70,
1022^1028.
*Gersons, B. P., Carlier, I.V., Lamberts, R. D., et al
(2000) Randomized clinical trial of brief eclectic

psychotherapy for police officers with posttraumatic

stress disorder. Journal of Traumatic Stress,
Stress, 13,
13, 333^347.
Hackmann, A., Ehlers, A., Speckens, A., et al (2004)

Characteristics and content of intrusive memories of

PTSD and their changes with treatment. Journal of
Traumatic Stress,
Stress, 17,
17, 211^240.
Higgins, J. P.T. & Thompson, S. G. (2002) Quantifying
heterogeneity in a meta-analysis. Statistics in Medicine,
Medicine,
21,
21, 1539^1558.
*Ironson, G. I., Freund, B., Strauss, J. L., et al (2002)

Comparison of two treatments for traumatic stress: a

community-based study of EMDR and prolonged
exposure. Journal of Clinical Psychology,
Psychology, 58,
58, 113^128.
*Jensen, J. A. (1994) An investigation of eye movement

desensitization and reprocessing (EMDR) as a treatment

for posttraumatic stress disorder (PTSD) symptoms of
Vietnam combat veterans. BehaviorTherapy,
BehaviorTherapy, 25,
25, 311^325.
*Keane, T. M., Fairbank, J. A., Caddell, J. M., et al
(1989) Implosive (flooding) therapy reduces symptoms

of PTSD in Vietnam combat veterans. Behavior Therapy,

Therapy,
20,
20, 245^260.
*Krakow, B., Hollifield, M., Johnston, L., et al (2001)

Imagery rehearsal therapy for chronic nightmares in

sexual assault survivors with posttraumatic stress

Cognitive trauma therapy for battered women with

PTSD: preliminary findings. Journal of Traumatic Stress,
Stress,
16,
16, 81^91.
*Kubany, E. S., Hill, E. E. & Owens, J. A. (2004)

Cognitive trauma therapy for battered women with

PTSD (CTT^ BW). Journal of Consulting and Clinical
Psychology,
Psychology, 72,
72, 3^18.
*Lange, A., Rietdijk, D., Hudcovicova, M., et al
(2003) Interapy: a controlled randomized trial of the

standardized treatment of posttraumatic stress through

the internet. Journal of Consulting and Clinical Psychology,
Psychology,
71,
71, 901^909.
*Lee, C., Gavriel, H., Drummond, P., et al (2002)

Treatment of post-traumatic stress disorder: a

comparison of stress inoculation training with prolonged
exposure and eye movement desensitization and
reprocessing. Journal of Clinical Psychology,
Psychology, 58,
58,
1071^1089.
*Marcus, S., Marquis, P. & Sakai, C. (1997)

Controlled study of treatment of PTSD using EMDR in

an HMO setting. Psychotherapy,
Psychotherapy, 34,
34, 307^315.
*Marks, I., Lovell, K., Noshirvani, H., et al (1998)

Treatment of posttraumatic stress disorder by exposure

and/or cognitive restructuring: a controlled study.
Archives of General Psychiatry,
Psychiatry, 55,
55, 317^325.
Moher, D., Pharn, B., Jones, A., et al (1998) Does
quality of reports of randomised trials affect estimates of
intervention efficacy in meta-analyses? Lancet,
Lancet, 352,
352,
609^613.
National Collaborating Centre for Mental Health
(2004) Clinical Guideline 23. Depression: Management of

Depression in Primary and Secondary Care.

Care. National
Institute for Clinical Excellence.
National Collaborating Centre for Mental Health
(2005) Clinical Guideline 26. Post-Traumatic Stress

Disorder: The Management of PTSD in Adults and Children

in Primary and Secondary Care.
Care. National Institute for
Clinical Excellence.
National Collaborating Centre for Primary Care
(2004) Clinical Guideline 22. Anxiety: Management of

Anxiety (Panic Disorder,With or Without Agoraphobia, and

Generalized Anxiety Disorder) in Adults in Primary,
Secondary and Community Care.
Care. National Institute for
Clinical Excellence.
*Neuner, F., Schauer, M., Klaschik, C., et al (2004) A
comparison of narrative exposure therapy, supportive
counselling and psychoeducation for treating
posttraumatic stress disorder in an African refugee
settlement. Journal of Consulting and Clinical Psychology,
Psychology,
72,
72, 579^587.
*Paunovic, N. & Ost, L. G. (2001) Cognitive ^
behaviour therapy vs exposure therapy in the treatment
of PTSD in refugees. Behaviour Research and Therapy,
Therapy, 39,
39,
1183^1197.
*Peniston, E. G. & Kulkosky, P. J. (1991) Alpha ^ theta
brainwave neuro-feedback therapy for Vietnam
veterans with combat-related post-traumatic stress
disorder. Medical Psychotherapy,
Psychotherapy, 4, 47^60.
Pitman, R. K., Altman, B., Greenwald, E., et al (1991)

Psychiatric complications during flooding therapy for

post-traumatic stress disorder. Journal of Clinical
Psychiatry,
Psychiatry, 52,
52, 17^20.
*Power, K., McGoldrick, T., Brown, K., et al (2002) A
controlled comparison of eye movement desensitisation
and reprocessing versus exposure plus cognitive
restructuring versus waiting list in the treatment of

103

B I S S ON E T A L

AUTHORS PROOF
post-traumatic stress disorder. Clinical Psychology and
Psychotherapy,
Psychotherapy, 9, 299^318.
*Resick, P. A., Nishith, P.,Weaver,T. L., et al (2002) A

comparison of cognitive-processing therapy with

prolonged exposure and a waiting condition for the
treatment of chronic posttraumatic stress disorder in
female rape victims. Journal of Consulting and Clinical
Psychology,
Psychology, 70,
70, 867^879.
*Rothbaum, B. (1997) A controlled study of eye
movement desensitization and reprocessing in the
treatment of post-traumatic stress disordered sexual
assault victims. Bulletin of the Menninger Clinic,
Clinic, 61,
61,
317^334.
*Rothbaum, B. O., Astin, M. C. & Marsteller, F.
(2005) Prolonged exposure vs. EMDR for PTSD rape

victims. Journal of Traumatic Stress,

Stress, 18,
18, 607^616.

JONATHAN I. BISSON,
BISSON, Department of Psychological Medicine, Cardiff University; ANKE EHLERS,
EHLERS, Institute of
Psychiatry, Kings College London; ROSA MATTHEWS, STEPHEN PILLING,
PILLING, National Collaborating Centre for
Mental Health, London; DAVID RICHARDS,
RICHARDS, Department of Mental Health, University of York; STUART
TURNER,
TURNER, University College London, London, UK
Correspondence: Dr Jonathan Bisson, Department of Psychological Medicine, Monmouth House,
University Hospital of Wales, Heath Park,Cardiff CF14 4XN,UK. Email: bissonji@
bissonji @cf.ac.uk
(First received 5 January 2006, final revision 27 April 2006, accepted 2 June 2006)

imaginal exposure in the treatment of chronic

posttraumatic stress disorder. Journal of Consulting and
Clinical Psychology,
Psychology, 67,
67, 13^18.

disorder: a meta-analysis. Clinical Psychology and

Psychotherapy,
Psychotherapy, 5, 126^145.
*Vaughan, K., Armstrong, M. S., Gold, R., et al
(1994) A trial of eye movement desensitization

*Scheck, M., Schaeffer, J. A. & Gillette, C. (1998)

*Tarrier,
*Tarrier, N., Sommerfield, C., Pilgrim, H., et al
(1999b
(1999b) Cognitive therapy or imaginal exposure in the

Brief psychological intervention with traumatized young

women: the efficacy of eye movement desensitization
and reprocessing. Journal of Traumatic Stress,
Stress, 11,
11, 24^44.

treatment of post-traumatic stress disorder. Twelve

month follow-up. British Journal of Psychiatry,
Psychiatry, 175,
175,
571^575.

*Schnurr, P. P., Friedman, M. J., Foy, D. W., et al

(2003) Randomized trial of trauma-focused group

*Taylor,
*Taylor, S., Thordarson, D. S., Maxfield, L., et al
(2003) Comparative efficacy, speed, and adverse effects

therapy for posttraumatic stress disorder: results from

a Department of VeteransAffairs cooperative study.
Archives of General Psychiatry,
Psychiatry, 60,
60, 481^489.

of three PTSD treatments: exposure therapy, EMDR

and relaxation training. Journal of Consulting and Clinical
Psychology,
Psychology, 71,
71, 330^338.

*Tarrier, N., Pilgrim, H., Sommerfield, C., et al

(1999a
(1999a) A randomized trial of cognitive therapy and

Van Etten, M. L. & T

Taylor,
aylor, S. (1988) Comparative

10 4

efficacy of treatments for post-traumatic stress

compared to image habituation training and applied

muscle relaxation in post-traumatic stress disorder.
Journal of Behavior Therapy and Experimental Psychiatry,
Psychiatry,
25,
25, 283^291.
*Zlotnick, C., Shea, T. M., Rosen, K., et al (1997) An

affect-management group for women with

posttraumatic stress disorder and histories of childhood
sexual abuse. Journal of Traumatic Stress,
Stress, 10,
10, 425^436.
*Studies that were part of the meta-analysis.

DATA SUP P LE
L E MENT TO B R IT I S H J O U R NA L O F P SYC H IAT RY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4

Table
Table DS1 Studies included in the meta-analysis

Study reference

Participants ran-

Age, years

Female

Traumatic

Mean duration

Types of

Duration

PTSD

Follow-up

domised/

mean (s.d.)1

events

of symptoms/

treatment

of

outcome

period

in post-

time since

and control

treatment

measures

treatment

trauma

and country

Randomisation

ITT

Masking

analysis

of

concealment

assessor

analysis, n
Brom et al,
al, 1989

112

42 (14.3)

79

Mixed

(The Netherlands) 100 completed

Less than

OT1 (psycho-

Mean 14^19

SCL^90 (trauma

Post-

5 years

dynamic

sessions

symptoms)

treatment,
3 MFU

(12 drop-outs

therapy)

IES

reported)

OT2

(intrusion and

(hypnotherapy)

avoidance)

Not given

Completers

Not given

only

TFCBT (trauma desensitisation)

Waiting list
Cooper & Clum

22 randomised

1989 (USA)

14 included in

37

Combat

Not given

TFCBT

Six to fourteen

Self-monitoring

Post-

(imaginal

1.5 h sessions

of

treatment

analysis (8 did

flooding)

including

re-experiencing

3 MFU

not complete)

Standard care

introduction

symptoms and

(psychological

and assess-

sleep

and pharma-

ment

Modified Vietnam

cological)

(maximum 9

Experiences Ques-

active flooding

tionnaire (non-vali-

sessions)

dated)

(Vietnam)

Not given

Completers

Not given

only

Behavioural
avoidance test
SUDS
Keane et al,
al, 1989

24

(USA)

24 completed

34.6 (4.3)

Combat

Not given

(Vietnam)

TFCBT

Fourteen to

PTSD symptom

Post-

(implosive

sixteen 90 min

checklist

treatment

flooding)

sessions

(Jackson

6 MFU (CBT),

Structured

4.5 MFU

Interview)

(waiting list)

Waiting list

Not given

Yes

No

Not given

Completers

Not given

MMPI (PTSD
sub-scale)
Foa et al,
al, 1991

45

(USA)

35

31.8 (8.2)

100

Rape

6.2 (6.7)

SM (stress

years

inoculation)
TFCBT (prolonged

13.5 h

Clinician-rated

Post-

PTSD severity

treatment,

only

3 MFU

exposure)
OT (supportive
counselling)
Waiting list

(Continued)

DATA SUP P LE
L E MENT TO B R IT I S H J O U R NA L O F P SYC H IAT RY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4

Peniston &

29

Kulkosky, 1991

29

36.6 (2.82)

Combat

12^15 years

(Vietnam)

(USA)
Jensen, 1994

29

(USA)

25

Vaughan et al,
al,

36

1994 (Australia)

36

41.3 (2.84)

Combat

Not given

TFCBT (neuro-

4 h pre-

feedback

training+

treatment,

evaluation

training)

15 h active

30 MFU

of MMPI

Usual care

intervention

EMDR Control

Not given

Structured

Post-

(3 sessions in all)

Interview for

treatment

(Vietnam)
32 (14.7)

64

Mixed

Not given

MMPI^R

Post-

Yes

Masked

data

PTSD

only

EMDR

Four 50 min

PTSD

Post-

TFCBT (image

sessions (all

Structured

treatment,

habituation

conditions)

Interview

3 MFU

training)

Not given

Not given

Completers

Not given

only
Not given

Yes

Yes

Not given

Yes

No

Not given

Unclear

No

Not given

Completers

No (inde-

only

pendent

IES

SM (applied
muscle
relaxation)
Echeburua et
et al,
al,

20

20 (7.09)

100

1997 (Spain)

Sexual

Not given

TFCBT (gradual

Six 70 min self-

aggression

self-exposure

exposure sessions interview

treatment,

(childhood and

and cognitive

Six 45 min

1MFU, 3 MFU,

adult)

restructuring)

relaxation sessions Scale of Severity

Structured
(scored on

Post-

6 MFU, 12 MFU

SM (progressive

of PTSD

relaxation training)

Symptoms)

EMDR

No set duration;

Modified PTSD

Mid-therapy

Standard care

at least three

scale

(after 3

drop-out

(including

50 min sessions

IES

sessions),

reported)

psychological and

SCL^90

post-treatment

pharmacological)

SUDS

Marcus et al,
al,

67

1997 (USA)

66 completed (1

Rothbaum, 1997

21

(USA)

18 completed (3

41.0 (range

79

Mixed

Not given

18^73)

34.2 (11.1)

100

Rape

Not given

EMDR

One

Structured

Post-

(adulthood)

Mean 104

Waiting list

information-

interview (PSS)

treatment,
3 MFU

drop-outs

months

gathering

IES

reported)

since rape

session then

Rape Aftermath

(s.d.106.6)
(s.d. 106.6)

three 90 min

Symptom Test

but not
masked)

active EMDR
sessions
Zlotnick et al,
al,

48

1997 (USA)

33 completed

39 (9.59)

100

Childhood

Not given

Group CBT

One 2 h session

CAPS^1

Post-

sexual abuse

Mean age of

(affect manage-

per week for

Davidson

treatment

(13 drop-outs

first abuse

ment group)

15 weeks

Trauma Scale

reported;

6.86 years

Waiting list

2 unaccounted

(s.d.2.36)
(s.d. 2.36)

Not given

Completers

Not given

only

SCL^90^R

for)
(Continued)
Continued)

DATA SUP P LE
L E MENT TO B R IT I S H J O U R NA L O F P SYC H IAT RY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4

Carlson et al,
al,
1998 (USA)

Marks et al,
al,
1998 (UK)

35
34 completed
(1 drop-out up
to posttreatment
assessment,
30 at 3 MFU,
12 at 9 MFU)
87
77 completed
(10 drop-outs
reported)

CAPS^1
PTSD Symptom
Scale
IES
Mississippi Scale
for CombatRelated PTSD

Not given
Posttreatment (all)
3 MFU, 9 MFU
(intervention
groups only)

TFCBT 1
(prolonged
imaginal and
live exposure
therapy)
TFCBT 2 (cognitive
restructuring)
TFCBT 3
(combined
prolonged
exposure and
cognitive
restructuring)
SM (relaxation)
EMDR
Two 90 min
OT (active
sessions (both
listening)
conditions)

CAPS^2
IES
PSS

Not given
Posttreatment,
1MFU, 3 MFU,
6 MFU

Penn Inventory
for PTSD
IES

Posttreatment,
3 MFU

Not given

Completers
only

TFCBT
(CBT ^ trauma
treatment
protocol)
EMDR

SCL^90^R
SUDS
Civilian
Mississippi Scale
for PTSD
IES
PSS^SR
PTSD Interview
CAPS
IES
PSS^I

Posttreatment,
2 weeks,
3 months

Not given

Completers
only

6 MFU

Not given

12 MFU

Not given

Completers Not given

only
Completers Not given
only

48 (8.6)

Combat

Not given

EMDR
SM
(biofeedbackassisted relaxation) Waiting list

38 (10)

36

Various

At least 6
months,
mean 46
months
(s.d.58)
(s.d. 58)

100

Mixed: 50%
sexual trauma

Not given

Scheck et al,
al,
1998 (USA)

67
20.9
60 completed (7 (range 16^25)
drop-outs reported)

Devilly & Spence,

1999 (Australia)

32
23 completed (9
drop-outs reported)

37.96 (12.82)

Fecteau & Nicki,

1999 (Canada)
Foa et al,
al, 1999
(USA)

23
20
96
79

41.3
(range 25^63)
34.9 (10.6)

65
Not given
(of completers)

70

RTA

100

Assault of
which 72%
sexual assault

Not given

18.8 months
(mean)
Not given

EMDR: twelve
60^75 min
sessions over
6 weeks
Relaxation:
twelve 40 min
sessions over
6 weeks
All conditions,
ten 90 min sessions (105 min for
combined group)

CBT: nine
sessions (6

(6
90 min
+3
120
+3 120 min)
EMDR: up to
eight
90^120 min
sessions
TFCBT
8h
Waiting list
approximately
TFCBT (exposure 10.5 h
therapy) SM (stress
inoculation training) TFCBT+SM
(combination exposure and stress
inoculation)
Waiting list

Completers Postonly
treatment/
3 MFU masking unclear
Masked
assessment
reported at
9 MFU
Yes
Completers
only

Masked administration
at end-point,
masking of
assessment
unclear
3 MFU not
masked
Not given

(Continued)

DATA SUP P LE
L E MENT TO B R IT I S H J O U R NA L O F P SYC H IAT RY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4

Tarrier et al,
al,

72

TFCBT 1

Sixteen 60 min

IES

Post-

1999a
1999a (UK)

62 completed;

37.9 (11.8)

41

Mixed

Not given

(imaginal

sessions in both

CAPS

treatment,

57 at 6 MFU,

exposure)

conditions

Penn Inventory for 12 MFU

54 at 12 MFU

TFCBT 2 (cogni-

(mean

PTSD

tive therapy)

attendance

Not given

Completers

Yes

only

11.2 sessions,
s.d.4.5)
s.d. 4.5)
Tarrier et al,
al,

72

1999b
1999b (UK)

62 completed

8.6 (11.6)

42

Mixed

34% 512

TFCBT 1

Sixteen sessions

IES

(non-CSA)

months

(imaginal

60 min in both

CAPS

40%

exposure)

conditions

Penn Inventory for

1^2 years

TFCBT 2 (cognitive

26%

therapy)

57 at 6 MFU

6 MFU

Not given

Completers

Yes

only

PTSD

2^10 years
Gersons et al,
al,

42

2000

23 completed

36.5 (7)

22

(The Netherlands) (1 drop-out

included in

Traumatic

3 years

TFCBT (brief

event at work

eclectic psy-

(all police

chotherapy)

officers)

Waiting list

16 h

Clinician-rated

3 MFU

Not given

Yes

Yes

6 MFU

Not given

Completers

Not given

PTSD symptoms

analysis)
Classen et al,
al,

55

2001
2001 (USA)

52

Not given

100

Adult

Not given

Group TFCBT

36 h

Trauma

survivors

(trauma-focused

Symptom

of CSA

group therapy)

Checklist^40

only

Group CBT
(present-centred
group therapy)
Waiting list
Krakow et al,
al,

168

Group CBT (group Three 3 h

DSS

Post-

2001
2001 (USA)

114 (end-point)

(adult and

imagery rehearsal) sessions

CAPS

treatmemt,

96 (3 MFU)

CSA)

Waiting list

36.9 (12.7)

100

Sexual assault

Not given

Not given

Yes

Yes

Not given

Completers

No

3 MFU, 6 MFU

99 (6 MFU)
Paunovic & Ost,

20

Mixed

7.8 years

TFCBT 1

Sixteen to

CAPS^IV

Post-

2001
2001 (Sweden)

16 completed

(refugee

(s.d.7.0)
(s.d. 7.0)

(trauma-

twenty

IES^R

treatment,

(4 drop-outs
reported)

population)

focused CBT)
TFCBT 2 (expo-

60^120 min
(both

PSS

6 MFU

sure therapy)

conditions)

TFCBT (CBT

20 h

CAPS

9 MFU

Cloitre et al,
al,

58

2002 (USA)

46

37.9 (7.6)

34 (7.22)

19

100

Adult

Not given

survivors

and modified

Modified

of CSA

prolonged

PSS^SR

only

Not given

Completers

Not given

only

exposure)
Waiting list
(Continued)
Continued)

DATA SUP P LE
L E MENT TO B R IT I S H J O U R NA L O F P SYC H IAT RY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4

Ironson et al,
al,
2002 (USA)

Limited data
22
19 completed given (range 16^
62 years)
(3 drop-outs reported)
12 at 3 MFU

Lee et al,
al, 2002
(USA)

24
21 completed
(3 drop-outs reported)

Power et al,
al,
2002 (UK)

105
72 completed
(33 drop-outs
reported)

Completers:
39.2 (11.8)

Resick et al,
al, 2002
(USA)

171
121 completed
(50 drop-outs
reported)

32 (9.9)

Blanchard et al,
al, 2003 73
(USA)
53

Bryant et al,
al,
2003 (Australia)

58
45 completed

Kubany et al,
al,
2003 (USA)

37
32 completed (5
drop-outs reported)
25 at 3 MFU

35.3 (17.16)

41 (13.1)

35.2 (12.31)

36.4 (9.1)

SUDS
PostIn both
EMDR
PSS^SR
treatment,
conditions
TFCBT (pro3 MFU
longed exposure) 3 non-active
sessions, 3 active
sessions with
homework
PostSeven 90 min
SI^PTSD
46
Mixed
Time since trau- EMDR
treatment,
sessions
IES
ma: mean 14.9 SM+TFCBT
Keanes PTSD scale 3 MFU
(stress inoculation
months
from the MMPI
training with
(s.d.15.71)
(s.d. 15.71)
prolonged
exposure)
PostMaximum of
CAPS
EMDR
58 (of
Mixed
Time since
treatment,
ten 90 min sessions IES
TFCBT
completers)
trauma
15 MFU
SI^PTSD (self(completers): (cognitive
report version)
restructuring
mean 199.3
and exposure
weeks
therapy)
(s.d.426)
(s.d. 426)
Waiting list
PostTFCBT 1 (cogni- Total 13 h active CAPS
100
Rape (during At least 3
PSS
treatment,
treatment over
months since tive processing
childhood
3 MFU, 9 MFU
6 weeks, plus
trauma, mean therapy)
and/or
homework
TFCBT 2
8.5 years
adulthood)
(TFCBT 1 mean
(prolonged
(s.d.8.5)
(s.d. 8.5)
22.6 h, TFCBT 2
exposure)
Minimal attention mean 44.8 h)
CAPS
3 MFU
8^12 sessions
73
RTA
9.8^15.1 months TFCBT
IES
(length
OT (supportive
average
unspecified)
psychotherapy)
duration
Waiting list
across treatment groups
CAPS^2
PostAll conditions:
Mininum
TFCBT 1
52
Mixed
IES
treatment,
eight 90 min
3 months
(prolonged
(excluding
6 MFU
sessions
imaginal
sexual assault)
exposure and
cognitive
restructuring)
TFCBT 2 (prolonged imaginal exposure)
OT (supportive
counselling)
Mean 8.5 (range 7^ CAPS
PostNot given
TFCBT
100
Mixed
11) sessions
treatment,
(cognitive
traumas within a
(90 min)
3 MFU
trauma therapy
population of
for battered
battered
women)
women
Waiting list
77

Mixed

Not given

Not given

Completers
only

No

Not given

Completers
only

No

Not given

Completers
only

Yes

Not given

Yes

Not given

Not given

Completers
only

Yes

Not given

Yes

Yes

Not given

Yes

Yes

DATA SUP P LE
L E MENT TO B R IT I S H J O U R NA L O F P SYC H IAT RY ( 2 0 0 7 ) , 1 9 0 , 9 7 ^ 1 0 4

Lange et al,
al, 2003
184
(The Netherlands) 101
101 at post-

Completers:
39.0 (10.5)

80

Mixed

At least 3
months since

treatment

trauma, mean

(83 drop-outs

9.0 years

reported)

(s.d.11.6)
(s.d. 11.6)

Interapy
Waiting list

Ten 45 min writing SCL^90

exercises
IES

Posttreatment,

Not given

Completers
only

Not given

Not given

Both

Yes

6 weeks FU

57 at 6 weeks
Taylor et al,
al, 2003

60

(Canada)

45 completed

37 (10)

75

Schnurr et al,
al,
2003 (USA)

360
253 completed
(325 participated in
follow-up)

50.7 (3.7)

Ehlers et al,
al,
2005 (UK)

28
28

36.6 (11.2)

Kubany et al,
al,
2004 (USA)

125
85 analysed
post-treatment

Neuner et al,
al,
2004 (Germany)

Rothbaum et al,
al,
2005 (USA)

Mixed

Mean

EMDR

All conditions:

CAPS

Post-

duration

TFCBT

eight 90 min

PSS

treatment,

completer and

8.7 years
(s.d.10.8)
(s.d. 10.8)

(exposure
therapy)

sessions

3 MFU

(limited) ITT
analyses re-

Combat
(Vietnam)

Not given

53.5

Mixed

11.5 months
(median)

42.2 (10.1)

100

Mixed
traumas
within a
population
of battered
women

43
40 analysed
posttreatment,
38 at 12 MFU

33.1 (7.9)

60

Refugee
population
(Sudanese
civil war)

Where
trauma was
partner
abuse,
mean 5.0
years since
last abuse
(s.d.7.4)
(s.d. 7.4)
Mean 7.5 years
since worst
trauma
(s.d.3.3)
(s.d. 3.3)

74
60 completed

Completers:
33.77 (11.03)

100

More than
Rape in
adulthood (4
(412 3 months
since trauma
years
old)

SM (relaxation)
Both conditions:
Group TFCBT
thirty 90^
Group CBT
120 min sessions,
(presentthen five 90 min
centred
booster sessions
group
therapy)
Up to 15
TFCBT
sessions
(trauma(mean 12.4)
focused
cognitive
therapy)
Waiting list
TFCBT (immediate 8^11 sessions
of 90 min
cognitive
trauma therapy)
Waiting list

TFCBT and
TFCBT
OT 1: four
(narrative
90^120 min
exposure
sessions
therapy)
Psychoeducation:
OT 1
one
(supportive
90^120 min
counselling)
Psychoeducation session
TFCBT (prolonged Both conditions:
nine 90 min
exposure)
sessions
EMDR
Waiting list

CAPS
PTSD
Checklist
SF^36

CAPS
PDS

Not given
Posttreatment,
12 months
(end of booster
period) 18 MFU,
24 MFU
6 MFU
Not given

ported
Yes

Yes

Yes

Yes

CAPS
Distressing
Event
Questionnaire

PostNot given
treatment,
3 MFU, 6 MFU

Both completer and

ITT analyses
reported

Yes

PDS
CIDI^PTSD
part

PostNot given
treatment,
4 MFU, 12 MFU

Completers
only

Yes

CAPS
SCID
PSS^SR
IES^R

Post-treatment, Not given

6 MFU, 12 MFU

Completers
only

Yes

CAPS, Clinician Administered PTSD Scale; CBT, cognitive ^behavioural therapy; CIDI, Composite International Diagnostic Interview; CSA, childhood sexual abuse; DSS, Depression Symptom Scale; EMDR, eye movement desensitisation and reprocessing;
IES(^R), Impact of Events Scale (Revised); ITT, intention-to-treat; MFU, months of follow-up; MMPI(^R), Minnesota Multiphasic Personality Interview (Revised); OT, other therapies; PDS, PTSD Diagnostic Scale; PSS(I, SR), PTSD Symptom Scale (Interview,
Self-Report); PTSD, post-traumatic stress disorder; RTA, road traffic accident; SCID, Structured Clinical Interview for DSM^IV; SCL^90 ^R, Symptom Checklist 90 ^ Revised; SI^PTSD, Structured Interview for PTSD; SM, stress management; SUDS,
Subjective Units of Distress Scale; TFCBT, trauma-focused cognitive ^behavioural therapy.
1. Where standard deviations are given for each treatment group separately, the highest across treatment groups is reported.

Psychological treatments for chronic post-traumatic stress

disorder: Systematic review and meta-analysis

JONATHAN I. BISSON, ANKE EHLERS, ROSA MATTHEWS, STEPHEN PILLING, DAVID RICHARDS
and STUART TURNER
BJP 2007, 190:97-104.
Access the most recent version at DOI: 10.1192/bjp.bp.106.021402

Supplementary
Material
References
Reprints/
permissions
You can respond
to this article at
Downloaded
from

Supplementary material can be found at:

http://bjp.rcpsych.org/content/suppl/2007/02/01/190.2.97.DC1.html
This article cites 46 articles, 2 of which you can access for free at:
http://bjp.rcpsych.org/content/190/2/97#BIBL
To obtain reprints or permission to reproduce material from this paper, please
write to permissions@rcpsych.ac.uk
/letters/submit/bjprcpsych;190/2/97
http://bjp.rcpsych.org/ on May 25, 2015
Published by The Royal College of Psychiatrists

To subscribe to The British Journal of Psychiatry go to:

http://bjp.rcpsych.org/site/subscriptions/