Trauma-focused psychotherapies for post-traumatic stress disorder: a systematic review and network meta-analysis

INTRODUCTION: Meta-analytic reviews suggest similar outcomes across trauma-focused psychotherapies for adults with post-traumatic stress disorder (PTSD). However, this conclusion may be premature due to suboptimal statistical-review methodologies. Network meta-analysis (NMA) allows a detailed rank-ordering of the efficacy of established psychotherapy interventions derived from indirect evidence as well as results from direct head-to-head comparisons. OBJECTIVE: We sought to determine the efficacy and attrition rates of psychotherapy interventions for PTSD by applying NMA. METHODS: We searched EMBASE, PsychINFO, PTSDPubs and PubMed for randomised controlled trials that compared psychotherapies either head-to-head or against controls for adults with PTSD. A frequentist NMA was used to compare direct and indirect effects to determine the efficacy and attrition rates of psychotherapy interventions. RESULTS: Of the 5649 papers identified, 82 trials comprising of 5838 patients were included. The network comprised 17 psychotherapies and four control conditions. Network estimates indicated superior efficacy of meta-cognitive therapy and cognitive processing therapy over other psychotherapies (ESs between 0.26 and 2.32). Written exposure therapy and narrative exposure therapy were associated with lower risk of drop out when considered alongside other psychotherapies. Confidence in the network meta-analytic estimates was considered moderate for both outcomes. CONCLUSIONS: In broad terms, therapeutic commensurability was evident. Nevertheless, with additional studies and larger sample sizes, meta-cognitive and written exposure therapies could indeed differentiate themselves from other approaches as having favourable efficacy and acceptability respectively. These findings may inform clinical decision-making, as well as guide future research for PTSD.