1. A Summary of a Systematic Review Robert Williams, LCSW, BCD University of Utah

2.   Bisson J, Andrew M. Psychological treatment of post- traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003388. Retrieved Jan 25, 2012 from www.onlinelibrary.wiley.com Study Details

3.   To perform a systematic review of randomized controlled trials of all psychological treatments following the guidelines of The Cochrane Collaboration. Objectives

4.   There is evidence that individual trauma focused CBT, EMDR, Stress Management and group TFCBT are effective treatments of PTSD.  Other non-trauma focused psychological treatments did not reduce PTSD symptoms as significantly  Some evidence that individual TFCBT and EMDR are superior to stress management at 2 to 5 months post treatment and TFCBT and EMDR are superior to other therapies  Trauma focused treatments are more effective than non- trauma focused treatments. Plain Language Summary

5.   Searched the Cochrane Optimal RCT search strategy using the following words: PTSD, Trauma, Cognitive, Behavioural, exposure, EMDR, psychological, psychotherapy, psychodynamic, stress inoculation, relaxation, anxiety management  Databases: Medline, clinpsych, psychlit, Embase, Pilots (a specialized PTSD database maintained by theNational PTSDCentrein the USA), Trials Register of the Cochrane Depression, Anxietyand Neurosis Group, lilacs, psynebs, sociofile. Search Strategy

6.   Hand Search of Journal of Traumatic Stress, ISTSS Treatment Guidelines (Foa 200)  Reference lists of studies identified in the search  Internet Search of known websites and discussion for a  Personal communication with NICE guidelines development group who shared their searches and communication with 38 researchers  Abstracts/Dissertations from the meetings of the European International Societies of Traumatic Stress Studies Search Strategy (cont)

7.   All RCTs focusing on considering one or more defined psychological treatments to reduce PTSD symptoms.  All adult individuals suffering from traumatic stress symptoms at least 70% diagnosed with PTSD according to DMS or ICD criteria  There was no criteria for severity of symptoms  Multiple Interventions were considered Inclusion Criteria

8.   Individual Trauma Focused CBT  Includes Exposure Therapies  Stress management/relaxation  TFCBT Group Therapy  Non Trauma focused CBT group therapy  Other psychological Treatment  EMDR  Wait list/usual care Inclusion Criteria Intervention Types Included

9.   Primary measure was severity of clinician rated traumatic stress symptoms using a standardized measure such as the Clinician Administer PTSD Symptom Scale (Blake 1995)  Other Measures included:  Pt administered scales  Severity of anxiety scales  Droupout rates  PTSD diagnosis after treatment  Any adverse effects (increased symptomology) Inclusion Criteria Outcome Measure

10.   Assessed methodological quality using standard approach described in Cochrane Handbook.  Utilized a 23 criteria scale with scores between 0-2 total maximum score 46.  Double reviewed disagreements discussed between reviewers regarding study quality  Cutoff score was not identified in the review Exclusion Criteria

11.   Did not satisfy inclusion criteria  Less than 3 months follow up following trauma  Treatment for anger only  Relaxation treatments with no comparison  Comparison of two CBT techniques only Reasons for Exclusion

12.   There was no search flow diagram included in this Systematic review.  There was no information on the number of studies identified and screened.  Inclusion & exclusion numbers were acquired by counting studies noted in tables.  11 studies were excluded.  41studies were included in this systematic review. PRISMA Search Flow Diagram

13.   Data was summarized a pooled effects calculated using RevMan 4.1 software  Continuous outcomes were analyzed as standard mean differences.  Data were pooled using fixed effects meta-analysis except were heterogeneity was present  Heterogeneity was assessed with both the I Squared test and the chi-squared test of heterogeneity. Data Synthesis

14.   To achieve meaningful results as non-trauma focused group CBT, hypnotherapy, psychodynamic therapy and supportive counseling all had only one trial they were grouped into a group called other therapies.  The number of statistical analyses run was immense  Therapy groups were broken into subgroups by type of outcome measurement  Comparisons were then made of internal efficacy and comparison to other treatment modalities Statistical Analysis

15.   Potential Publication bias was noted by the reviewers  All of the studies in this review were published or accepted for publication  Potential effects of this bias were explored using funnel plots.  Smaller studies may tend to report larger between TFCBE and waitlist/usual care  Both suggest an absence of studies demonstrating no difference or a difference in favor of the waitlist/usual care  Due to greater likelihood of publication of positive studies it is possible true difference between groups is smaller than suggested by this review Biases

16.  Risk of Bias Well completedMinor errors/ Not explained Inadequate Protections Randomization726 Allocation Concealment 1276 Blinding2013 Loss to follow up11193

17.   There was good evidence TFCBT was better than wait list/usual care  Some evidence TFCBT was more effective than non- trauma focused therapies  TFCBT was significantly better than other therapies and than stress management at follow up Results Trauma Focused Cognitive Behavioral Therapy

18.   Evidence that stress management is better than wait list in reducing PTSD symptoms and symptoms of anxiety and depression  Based on two studies with small sample size Results Stress Management

19.   There was no difference between other therapies and waitlist/usual care on main outcome measure  Care recipients did fare better on self report traumatic stress and anxiety measure  Did not do as well with TFCBT and Stress Managment Results Other Therapies

20.   Evidence group TFCBT was better than waitlist care as usual  This was based on one study with small sample size  No difference between Group TFCBT and non- trauma focuses CBT Results Group TFCBT

21.   Evidence that EMDR was better than waitlist/care as usual in reducing traumatic stress symptoms and additionally symptoms associated with depression and anxiety  Included studies had small sample size and two lacked randomization concealment  As with TFCBT results may be stronger than suggested because of ongoing contact with wait list group  Clinician rated traumatic stress represents a strong positive effect size however self reported PTSD symptom severity did not reach statistical significance Results EMDR

22.   Psychological treatment can reduce traumatic stress symptoms  TFCBT and EMDR have best evidence for efficacy  Some limited evidence stress management is effective  More limited evidence that non trauma focused psychological treatments are effective  Drop-out from treatment is an issue with currently available treatment Author’s Conclusion

23.   Further well designed studies of psychological treatment are required that consider boundary issues  Large EMDR trials are required  There is a need for more treatment comparison trials  Further trial should enforce stronger quality control of intervention and control groups  Role of psychological treatment in combination and as an alternative to medication is unclear Author’s Conclusion

24.   Basis for Comparison  Differing kinds of therapies were grouped. How effective were the groupings.  Is mean difference the best statistical method? Questions/Concerns

25.  Questions?

26.   Bisson J, Andrew M. Psychological treatment of post- traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003388. Retrieved Jan 25, 2012 from www.onlinelibrary.wiley.com References

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