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Integrating fragmented evidence by network meta-analysis: relative effectiveness of psychological interventions for adults with post-traumatic stress disorder

Published online by Cambridge University Press:  16 April 2014

H. Gerger ,
T. Munder ,
A. Gemperli ,
E. Nüesch ,
S. Trelle ,
P. Jüni  and
J. Barth
H. Gerger*
Affiliation:
Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland Division of Clinical Psychology and Psychotherapy, Department of Psychology, University of Basel, Switzerland
T. Munder
Affiliation:
Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
A. Gemperli
Affiliation:
Department of Clinical Research, CTU Bern, University of Bern, Switzerland Swiss Paraplegic Research (SPF), Nottwil, Switzerland Department of Health Sciences and Health Policy, University of Lucerne, Switzerland
E. Nüesch
Affiliation:
Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland Department of Clinical Research, CTU Bern, University of Bern, Switzerland
S. Trelle
Affiliation:
Department of Clinical Research, CTU Bern, University of Bern, Switzerland
P. Jüni
Affiliation:
Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland Department of Clinical Research, CTU Bern, University of Bern, Switzerland
J. Barth
Affiliation:
Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland Institute of Complementary and Integrative Medicine, University Hospital of Zurich, Switzerland
*
*Address for correspondence: H. Gerger, Ph.D., Department of Clinical Psychology and Psychotherapy, University of Basel, Missionsstrasse 62, 4055 Basel, Switzerland. (Email: [email protected])
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Abstract

Background.

To summarize the available evidence on the effectiveness of psychological interventions for patients with post-traumatic stress disorder (PTSD).

Method.

We searched bibliographic databases and reference lists of relevant systematic reviews and meta-analyses for randomized controlled trials that compared specific psychological interventions for adults with PTSD symptoms either head-to-head or against control interventions using non-specific intervention components, or against wait-list control. Two investigators independently extracted the data and assessed trial characteristics.

Results.

The analyses included 4190 patients in 66 trials. An initial network meta-analysis showed large effect sizes (ESs) for all specific psychological interventions (ESs between −1.10 and −1.37) and moderate effects of psychological interventions that were used to control for non-specific intervention effects (ESs −0.58 and −0.62). ES differences between various types of specific psychological interventions were absent to small (ES differences between 0.00 and 0.27). Considerable between-trial heterogeneity occurred (τ2 = 0.30). Stratified analyses revealed that trials that adhered to DSM-III/IV criteria for PTSD were associated with larger ESs. However, considerable heterogeneity remained. Heterogeneity was reduced in trials with adequate concealment of allocation and in large-sized trials. We found evidence for small-study bias.

Conclusions.

Our findings show that patients with a formal diagnosis of PTSD and those with subclinical PTSD symptoms benefit from different psychological interventions. We did not identify any intervention that was consistently superior to other specific psychological interventions. However, the robustness of evidence varies considerably between different psychological interventions for PTSD, with most robust evidence for cognitive behavioral and exposure therapies.

Keywords

Meta-analysisoutcome researchpost-traumatic stress disorderpsychotherapyPTSD
Type
Original Articles
Information
Psychological Medicine , Volume 44 , Issue 15 , November 2014 , pp. 3151 - 3164
Copyright
Copyright © Cambridge University Press 2014 

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References

Altman, DG, Bland, JM (2003). Interaction revisited: the difference between two estimates. British Medical Journal 326, 219.Google Scholar
Barth, J, Munder, T, Gerger, H, Nüesch, E, Trelle, S, Znoj, H, Jüni, P, Cuijpers, P (2013). Comparative efficacy of seven psychotherapeutic interventions for patients with depression: a network meta-analysis. PLoS Medicine 10, e1 001 454.CrossRefGoogle ScholarPubMed
Benish, SG, Imel, ZE, Wampold, BE (2008). The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: a meta-analysis of direct comparisons. Clinical Psychology Review 28, 746–758.CrossRefGoogle ScholarPubMed
Bernat, JA, Ronfeldt, HM, Calhoun, KS, Arias, I (1998). Prevalence of traumatic events and peritraumatic predictors of posttraumatic stress symptoms in a nonclinical sample of college students. Journal of Traumatic Stress 11, 645–664.Google Scholar
Bisson, JI, Andrew, M (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews. Issue 3, Art. No.: CD003388.Google Scholar
Bradley, R, Greene, J, Russ, E, Dutra, L, Westen, D (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry 162, 214–227.CrossRefGoogle ScholarPubMed
Breslau, N (2009). The epidemiology of trauma, PTSD, and other posttrauma disorders. Trauma, Violence and Abuse 10, 198–210.CrossRefGoogle ScholarPubMed
Breslau, N, Davis, GC, Andreski, P, Peterson, E (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry 48, 216–222.Google Scholar
Breslau, N, Kessler, RC, Chilcoat, HD, Schultz, LR, Davis, GC, Andreski, P (1998). Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Archives of General Psychiatry 55, 626–632.CrossRefGoogle ScholarPubMed
Cipriani, A, Barbui, C, Salanti, G, Rendell, J, Brown, R, Stockton, S, Purgato, M, Spineli, LM, Goodwin, GM, Geddes, JR (2011). Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis. Lancet 378, 1306–1315.Google Scholar
Cipriani, A, Furukawa, TA, Salanti, G, Geddes, JR, Higgins, J, Churchill, R, Watanabe, N, Nakagawa, A, Omori, IM, McGuire, H, Tansella, M, Barbui, C (2009). Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis. Lancet 373, 746–758.Google Scholar
Cloitre, M (2009). Effective psychotherapies for posttraumatic stress disorder: a review and critique. CNS Spectrums 14, 32–43.Google Scholar
Cohen, J (1988). Statistical Power Analysis for the Behavioral Sciences, 2nd edn. Lawrence Erlbaum Associates: Hillsdale, NJ.Google Scholar
Cooper, NJ, Sutton, AJ, Lu, G, Khunti, K (2006). Mixed comparison of stroke prevention treatments in individuals with nonrheumatic atrial fibrillation. Archives of Internal Medicine 166, 1269–1275.CrossRefGoogle ScholarPubMed
Cuijpers, P, Li, J, Hofmann, SG, Andersson, G (2010 a). Self-reported versus clinician-rated symptoms of depression as outcome measures in psychotherapy research on depression: a meta-analysis. Clinical Psychology Review 30, 768–778.Google Scholar
Cuijpers, P, Van Straten, A, Bohlmeijer, E, Hollon, SD, Andersson, G (2010 b). The effects of psychotherapy for adult depression are overestimated: a meta-analysis of study quality and effect size. Psychological Medicine 40, 211–223.Google Scholar
Davidson, PR, Parker, KC (2001). Eye movement desensitization and reprocessing (EMDR): a meta-analysis. Journal of Consulting and Clinical Psychology 69, 305–316.Google Scholar
Egger, M, Davey Smith, G, Schneider, M, Minder, C (1997). Bias in meta-analysis detected by a simple, graphical test. British Medical Journal 315, 629–634.Google Scholar
Egger, M, Dickersin, K, Davey Smith, G (2001). Problems and Limitations in Conducting Systematic Reviews, 2nd edn. BMJ Books: London.CrossRefGoogle Scholar
Egger, M, Juni, P, Bartlett, C, Holenstein, F, Sterne, J (2003). How important are comprehensive literature searches and the assessment of trial quality in systematic reviews? Empirical study. Health Technology Assessment 7, 1–4.CrossRefGoogle ScholarPubMed
Ehlers, A, Clark, DM, Hackmann, A, McManus, F, Fennell, M (2005). Cognitive therapy for post-traumatic stress disorder: development and evaluation. Behaviour Research and Therapy 43, 413–431.CrossRefGoogle ScholarPubMed
Foa, EB, Rothbaum, BO, Riggs, DS, Murdock, TB (1991). Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology 59, 715–723.CrossRefGoogle ScholarPubMed
Follmann, D, Elliott, P, Suh, I, Cutler, J (1992). Variance imputation for overviews of clinical trials with continuous response. Journal of Clinical Epidemiology 45, 769–773.CrossRefGoogle ScholarPubMed
Frost, N, Laska, KM, Wampold, BE (2014). The evidence for present-centered therapy as a treatment for posttraumatic stress disorder. Journal of Traumatic Stress 27, 1–8.Google Scholar
Gerger, H, Munder, T, Barth, J (2013). Specific and non-specific psychological interventions for PTSD symptoms: a meta-analysis with problem complexity as a moderator. Journal of Clinical Psychology. Published online: 18 December 2013 . doi: 10.1002/jclp.22059.Google Scholar
Jüni, P, Altman, DG, Egger, M (2001). Systematic reviews in health care: assessing the quality of controlled clinical trials. British Medical Journal 323, 42–46.Google Scholar
Kessler, RC, Sonnega, A, Bromet, E, Hughes, M, Nelson, CB (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry 52, 1048–1060.CrossRefGoogle ScholarPubMed
Koren, D, Arnon, I, Klein, E (2001). Long term course of chronic posttraumatic stress disorder in traffic accident victims: a three-year prospective follow-up study. Behaviour Research and Therapy 39, 1449–1458.Google Scholar
Lu, G, Ades, AE (2004). Combination of direct and indirect evidence in mixed treatment comparisons. Statistics in Medicine 23, 3105–3124.Google Scholar
Lumley, T (2002). Network meta-analysis for indirect treatment comparisons. Statistics in Medicine 21, 2313–2324.CrossRefGoogle ScholarPubMed
Marshall, RD, Olfson, M, Hellman, F, Blanco, C, Guardino, M, Struening, EL (2001). Comorbidity, impairment, and suicidality in subthreshold PTSD. American Journal of Psychiatry 158, 1467–1473.Google Scholar
Matt, GE, Cook, TD (2009). Threats to the validity of generalized inferences. In The Handbook of Research Synthesis and Meta-Analysis, 2nd edn (ed. Cooper, H., Hedges, L. V. and Valentine, J. C.), pp. 537–560. Russell Sage: New York.Google Scholar
Mayou, RA, Ehlers, A, Bryant, B (2002). Posttraumatic stress disorder after motor vehicle accidents: 3-year follow-up of a prospective longitudinal study. Behaviour Research and Therapy 40, 665–675.CrossRefGoogle ScholarPubMed
Mendes, DD, Mello, MF, Ventura, P, de Medeiros Passarela, C, de Jesus Mari, J (2008). A systematic review on the effectiveness of cognitive behavioral therapy for posttraumatic stress disorder. International Journal of Psychiatry in Medicine 38, 241–259.CrossRefGoogle ScholarPubMed
Munder, T, Flückiger, C, Gerger, H, Wampold, BE, Barth, J (2012). Is the allegiance effect an epiphenomenon of true efficacy differences between treatments? A meta-analysis. Journal of Counseling Psychology 59, 631–637.Google Scholar
Norris, FH (1992). Epidemiology of trauma: frequency and impact of different potentially traumatic events on different demographic groups. Journal of Consulting and Clinical Psychology 60, 409–418.CrossRefGoogle ScholarPubMed
Nüesch, E, Trelle, S, Reichenbach, S, Rutjes, AWS, Bürgi, E, Scherer, M, Altman, DG, Jüni, P (2009). The effects of excluding patients from the analysis in randomised controlled trials: meta-epidemiological study. British Medical Journal 339, b3244.Google Scholar
Nüesch, E, Trelle, S, Reichenbach, S, Rutjes, AWS, Tschannen, B, Altman, DG, Egger, M, Jüni, P (2010). Small study effects in meta-analyses of osteoarthritis trials: meta-epidemiological study. British Medical Journal 341, c3515.Google Scholar
Perkonigg, A, Pfister, H, Stein, MB, Höfler, M, Lieb, R, Maerker, A, Wittchen, HU (2005). Longitudinal course of posttraumatic stress disorder and posttraumatic stress disorder symptoms in a community sample of adolescents and young adults. American Journal of Psychiatry 162, 1320–1327.Google Scholar
Peters, JL, Sutton, AJ, Jones, DR, Abrams, KR, Rushton, L (2008). Contour-enhanced meta-analysis funnel plots help distinguish publication bias from other causes of asymmetry. Journal of Clinical Epidemiology 61, 991–996.Google Scholar
Powers, MB, Halpern, JM, Ferenschak, MP, Gillihan, SJ, Foa, EB (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review 30, 635–641.CrossRefGoogle ScholarPubMed
Reichenbach, S, Sterchi, R, Scherer, M, Trelle, S, Bürgi, E, Bürgi, U, Dieppe, PA, Jüni, P (2007). Meta-analysis: chondroitin for osteoarthritis of the knee or hip. Annals of Internal Medicine 146, 580–590.Google Scholar
Resick, PA, Galovski, TE, Uhlmansiek, MOB, Scher, CD, Clum, GA, Young-Xu, Y (2008). A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. Journal of Consulting and Clinical Psychology 76, 243–258.Google Scholar
Resnick, HS, Kilpatrick, DG, Dansky, BS, Saunders, BE, Best, CL (1993). Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. Journal of Consulting and Clinical Psychology 61, 984–991.Google Scholar
Rücker, G, Schwarzer, G, Carpenter, JR, Schumacher, M (2008). Undue reliance on I2 in assessing heterogeneity may mislead. BMC Medical Research Methodology 8, 79.Google Scholar
Salanti, G, Higgins, JPT, Ades, AE, Ioannidis, JPA (2008). Evaluation of networks of randomized trials. Statistical Methods in Medical Research 17, 279–301.Google Scholar
Seidler, G, Wagner, F (2006). Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study. Psychological Medicine 36, 1515–1522.Google Scholar
Smith, TC, Spiegelhalter, DJ, Thomas, A (1995). Bayesian approaches to random-effects meta-analysis: a comparative study. Statistics in Medicine 14, 2685–2699.Google Scholar
Spiegelhalter, DJ, Best, NG, Carlin, BP, Van Der Linde, A (2002). Bayesian measures of model complexity and fit. Journal of the Royal Statistical Society: Series B (Statistical Methodology) 64, 583–639.Google Scholar
Stein, MB, Walker, JR, Hazen, AL, Forde, DR (1997). Full and partial posttraumatic stress disorder: findings from a community survey. American Journal of Psychiatry 154, 1114–1119.Google Scholar
Thompson, SG, Higgins, JPT (2002). How should meta-regression analyses be undertaken and interpreted? Statistics in Medicine 21, 1559–1573.Google Scholar
van Etten, ML, Taylor, S (1998). Comparative efficacy of treatments for post-traumatic stress disorder: a meta-analysis. Clinical Psychology and Psychotherapy 5, 126–144.Google Scholar
Walker, EA, Gelfand, A, Katon, WJ, Koss, MP, Von Korff, M, Bernstein, D, Russo, J (1999). Adult health status of women with histories of childhood abuse and neglect. American Journal of Medicine 107, 332–339.Google Scholar
Wampold, BE, Imel, ZE, Laska, KM, Benish, S, Miller, SD, Flückiger, C, Del Re, AC, Baardseth, TP, Budge, S (2010). Determining what works in the treatment of PTSD. Clinical Psychology Review 30, 923–933.Google Scholar
Watts, BV, Schnurr, PP, Mayo, L, Young-Xu, Y, Weeks, WB, Friedman, MJ (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry 74, e541–e550.Google Scholar
Wood, L, Egger, M, Gluud, LL, Schulz, KF, Jüni, P, Altman, DG, Gluud, C, Martin, RM, Wood, AJ, Sterne, JA (2008). Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study. British Medical Journal 336, 601–605.Google Scholar
Zlotnick, C, Franklin, CL, Zimmerman, M (2002). Does ‘subthreshold’ posttraumatic stress disorder have any clinical relevance? Comprehensive Psychiatry 43, 413–419.Google Scholar
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