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BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.
PMCID: PMC2907597

Post-traumatic stress disorder

Jonathan I Bisson, DM MRCPsych, Director of Research and Development

Abstract

Introduction

Post-traumatic stress disorder (PTSD) may affect 10% of women and 5% of men at some stage, and symptoms may persist for several years. Risk factors include major trauma, lack of social support, peritraumatic dissociation, and previous psychiatric history or personality factors.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent PTSD? What are the effects of interventions to treat PTSD? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 46 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review we present information relating to the effectiveness and safety of the following interventions: affect management; antiepileptic drugs; antihypertensive drugs; benzodiazepines; brofaromine; CBT; drama therapy; eye movement desensitisation and reprocessing; fluoxetine; group therapy; hydrocortisone; hypnotherapy; inpatient treatment programmes; Internet-based psychotherapy; mirtazapine; multiple-session CBT; multiple-session collaborative trauma support; multiple-session education; nefazodone; olanzapine; paroxetine; phenelzine; psychodynamic psychotherapy; risperidone; SSRIs (versus other antidepressants); sertraline; single-session group debriefing; single-session individual debriefing; supportive psychotherapy; supportive counselling; temazepam; tricyclic antidepressants; and venlafaxine.

Key Points

Post-traumatic stress disorder (PTSD) is characterised by disabling symptoms of re-experiencing a traumatic event, avoidance behaviour, and hyperarousal (e.g., irritability or hypervigilance), lasting at least 1 month.

  • PTSD may affect 10% of women and 5% of men at some stage, and symptoms may persist for several years.
  • Risk factors include major trauma, lack of social support, peritraumatic dissociation, and previous psychiatric or personality factors.

Multiple-session trauma-focused CBT may be effective at preventing development of PTSD in people with psychological distress after a traumatic event.

  • However, we don't know whether multiple-session trauma-focused CBT is beneficial for people who have experienced a traumatic event but have not been diagnosed with psychological distress.

We don't know whether antiepileptic drugs, antihypertensive drugs, hydrocortisone, multiple-session collaborative trauma support, multiple-session education, single-session group debriefing, or temazepam are beneficial in preventing PTSD.

In people with PTSD, trauma-focused CBT improves PTSD symptoms compared with no treatment or with other psychological interventions, including stress management and present-centred therapy. Eye movement desensitisation and reprocessing seems as effective as trauma-focused CBT in the treatment of chronic PTSD.

Paroxetine may improve symptoms in people with PTSD. However, venlafaxine does not seem effective at improving symptoms, and the benefits of fluoxetine are unclear.

About this condition

Definition

Post-traumatic stress disorder (PTSD) can occur after any major traumatic event. Symptoms include upsetting thoughts and nightmares about the traumatic event, avoidance behaviour, numbing of general responsiveness, increased irritability, and hypervigilance. To fulfil the Diagnostic and Statistical Manual-IV (DSM-IV) criteria for PTSD, an individual must have been exposed to a traumatic event; have at least one re-experiencing, three avoidance, and two hyperarousal phenomena; have had the symptoms for at least 1 month; and the symptoms must cause clinically important distress or reduced day-to-day functioning. It is labelled as acute for the first 3 months and chronic if it lasts beyond 3 months. People with subsyndromal PTSD have all the criteria for PTSD except one of the re-experiencing, avoidance, or hyperarousal phenomena. Acute stress disorder occurs within the first month after a major traumatic event and requires the presence of symptoms for at least 2 days. It is similar to PTSD, but dissociative symptoms are required to make the diagnosis. Treatments for PTSD may have similar effects, regardless of the traumatic event that precipitated PTSD. However, great caution should be applied when generalising from one type of trauma to another.

Incidence/ Prevalence

One large cross-sectional study in the USA found that 1/10 (10%) women and 1/20 (5%) men experience PTSD at some stage in their lives.

Aetiology/ Risk factors

Risk factors include major trauma, such as: rape; a history of psychiatric disorders; acute distress and depression after the trauma; lack of social support; and personality factors.

Prognosis

One large cross-sectional study in the USA found that over a third of people with previous PTSD continued to satisfy the criteria for PTSD 6 years after initial diagnosis. However, cross-sectional studies provide weak evidence about prognosis.

Aims of intervention

To reduce initial distress after a traumatic event; to prevent PTSD and other psychiatric disorders; to reduce levels of distress in the long term; to improve function and quality of life; with minimal adverse effects.

Outcomes

Prevention: incidence of PTSD; symptoms that may lead to a diagnosis of PTSD (anxiety, depression, avoidance, intrusive symptoms). Treatment: incidence of PTSD, and symptom severity assessed by continuous measures. Continuous measures for assessing changes in symptoms include Impact of Event Scale (range 0–75), Post-traumatic Stress Diagnostic Scale (range 0–51), Clinician Administered PTSD Scale (0–136), Trauma Symptom Checklist 40 (range 0–160), Post-traumatic Stress Disorder Checklist (17 items graded from 1 = not at all to 5 = extremely), and Clinical Global Impression Scale (a composite measure of symptoms and everyday functioning; range very much worse–very much improved). Symptoms assessed include anxiety, depression, intrusion, and avoidance. Changes in continuous measures are often expressed as effect sizes. It is difficult to interpret effect sizes in terms of clinical importance. Some categorise effect sizes of less than 0.5 as small, 0.5–0.8 as medium, and greater than 0.8 as large. Prevention and treatment: Adverse effects of treatment.

Methods

Clinical Evidence search and appraisal March 2009. The following databases were used to identify studies for this systematic review: Medline 1966 to March 2009, Embase 1980 to March 2009, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2009, Issue 1 (1966 to date of issue). An additional search was carried out for the Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA). We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the contributor for additional assessment, using predetermined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews of RCTs and RCTs in any language, at least single blinded, and containing more than 20 individuals of whom more than 80% were followed up. There was no minimum length of follow-up required to include studies. We excluded all studies described as “open”, “open label”, or not blinded unless blinding was impossible. We included systematic reviews of RCTs and RCTs where harms of an included intervention were studied applying the same study design criteria for inclusion as we did for benefits. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).

Table
GRADE Evaluation of interventions for Post-traumatic stress disorder.

Glossary

Affect management
A group treatment focusing on regulation of mood.
Anxiety management
Involves teaching techniques to reduce anxiety levels. Examples include muscular relaxation, in which individuals are taught to alternately tense and relax specific muscle groups and breathing retraining to avoid overbreathing.
Avoidance
A characteristic symptom of post-traumatic stress disorder, whereby reminders, thoughts, or situations that remind the individual of the trauma are avoided.
Clinical Global Impression Scale
A one-item, observer-rated scale for measuring the severity of a condition. It has been investigated for validity and reliability. The scale is scored from 0 (not ill at all) to 7 (severely ill).
Cognitive behavioural therapy
Covers a variety of techniques. Imaginal exposure entails exposure to a detailed account or image of what happened. Real life exposure involves confronting real life situations that have become associated with the trauma and cause fear and distress. Cognitive therapy entails challenging distorted thoughts about the trauma, the self, and the world. Eclectic psychotherapy is a combination of trauma-focused cognitive behavioural therapy and psychodynamic psychotherapy. Imaginal flooding involves the intense reliving of the traumatic experience. Memory structuring involves listening to and clarifying the individual's narrative and structuring it for them to repeat to friends and family. Prolonged exposure entails repeated exposure to memories of the trauma, and to non-dangerous real life situations that are avoided because of trauma related fear. Stress inoculation entails instruction in coping skills and some cognitive techniques such as restructuring. Supportive listening involves actively listening to the individual's narrative and clarifying factual, sensory, and affective details.
Dissociative symptoms
Involves a disruption to memory or perception of the environment; for example, an inability to recall details of a traumatic event that cannot be accounted for by ordinary forgetfulness or an organic cause such as head injury.
Drama therapy
Uses drama as a form of expression and communication.
Eye movement desensitisation and reprocessing (EMDR)
Involves asking the person to focus on the traumatic event, a negative cognition associated with it, and the associated emotions. The person is then asked to follow the therapist's finger as it moves from side to side.
High-quality evidence
Further research is very unlikely to change our confidence in the estimate of effect.
Hyperarousal
A characteristic group of symptoms in post-traumatic stress disorder, including increased irritability, sleeping difficulties, hypervigilance, increased startle, and reduced concentration.
Hypnotherapy
Involves hypnosis to allow people to work through the traumatic event.
Inpatient treatment programmes
Individuals receive a planned package of care, usually as a group, as inpatients. The programmes can include various techniques, including cognitive behavioural therapy, group therapy, and medication.
Internet-based psychotherapy
A protocol-driven treatment delivered through the internet, which includes psychoeducation and cognitive reappraisal.
Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Present focused group therapy
A group intervention that involves identifying and modifying patterns of behaviour that have arisen from their past traumatic experience.
Psychological debriefing
Detailed consideration of the traumatic event and the normalisation of psychological reactions.
Subsyndromal post-traumatic stress disorder
This term is sometimes used to describe individuals with traumatic stress symptoms who would not fulfil the full Diagnostic and Statistical Manual (DSM)-IV or International classification of mental and behavioural disorders (ICD-10) criteria for a diagnosis of post-traumatic stress disorder.
Supportive counselling
A non-directive intervention dealing with current issues rather than the trauma itself.
Supportive psychotherapy
A non-directive intervention that involves helping an individual to explore their thoughts, feelings, and behaviour with the aim of achieving a clearer understanding of self and the ability to cope with situations more effectively.
Trauma focused group therapy
A group intervention that involves reconstructing a past traumatic event, identifying and modifying negative self images associated with it, and integrating memories of the event into the individual's conscious awareness of self and others.
Very low-quality evidence
Any estimate of effect is very uncertain.

Notes

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

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BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Antiepileptic drugs to prevent PTSD

Summary

We don't know whether antiepileptic drugs are beneficial in preventing PTSD.

Benefits and harms

Antiepileptics versus placebo:

We found no systematic review on the effects of antiepileptics in the prevention of PTSD. We found one small three-arm RCT.

Incidence of PTSD

Gabapentin compared with placebo We don't know whether gabapentin is more effective than placebo at reducing the proportion of people diagnosed with PTSD in people who have experienced a severe injury (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

RCT
3-armed trial
48 people admitted to a surgical trauma centre with severe injuries Proportion of people diagnosed with PTSD (assessed using various scales) 4 months
2/10 (20%) with gabapentin (initially 300 mg three times daily increasing to 400 mg three times daily over 2 days)
4/16 (25%) with placebo

Significance not assessed
People with and without risk factors for PTSD after injury were enrolled in the RCT
The RCT may have been underpowered to detect clinically meaningful differences between groups

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
3-armed trial
48 people admitted to a surgical trauma centre with severe injuries Adverse effects 4 months
with gabapentin (initially 300 mg three times daily increasing to 400 mg three times daily over 2 days)
with placebo
Absolute results not reported

Further information on studies

None.

Comment

None.

Substantive changes

Antiepileptic drugs to prevent PTSD One small RCT added found that a similar proportion of people with a severe injury was diagnosed with PTSD at 4 months' follow-up after initial treatment with gabapentin for 14 days compared with those given placebo. The RCT was underpowered to detect a clinically meaningful difference. Categorisation unchanged (Unknown effectiveness).

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Antihypertensive drugs to prevent PTSD

Summary

We don't know whether antihypertensive drugs are beneficial in preventing PTSD.

Benefits and harms

Antihypertensive drugs versus placebo:

We found no systematic review assessing the effects of antihypertensives in the prevention of PTSD. We found two RCTs assessing the effects of propranolol.

Incidence of PTSD

Compared with placebo We don't know whether propranolol is more effective than placebo at reducing the proportion of people diagnosed with PTSD at 3 to 4 months in people who have experienced a traumatic event or severe injury (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

RCT
41 people with early symptoms of PTSD 6 hours after a traumatic event Proportion of people with PTSD (measured by Clinician Administered Post-traumatic Stress Disorder Scale) 1 month
2/11 (18%) with propranolol 40 mg four times daily for 10 days
6/20 (30%) with placebo

RR 0.52
95% CI 0.09 to 3.16
The follow-up of the RCT is 75%, which is slightly below our reporting criteria of 80%. However, because of the paucity of data on the effects of propranolol in the prevention of PTSD, we have decided to include this RCT
Not significant

RCT
41 people with early symptoms of PTSD 6 hours after a traumatic event Proportion of people with PTSD (measured by Clinician Administered Post-traumatic Stress Disorder Scale) 3 months
1/11 (9%) with propranolol 40 mg four times daily for 10 days
2/15 (13%) with placebo

RR 0.65
95% CI 0.05 to 8.23
The follow-up of the RCT is 75%, which is slightly below our reporting criteria of 80%. However, because of the paucity of data on the effects of propranolol in the prevention of PTSD, we have decided to include this RCT
Not significant

RCT
3-armed trial
48 people admitted to a surgical trauma centre with severe injuries Proportion of people diagnosed with PTSD (assessed using various scales) 4 months
3/12 (25%) with propranolol (initially 20 mg three times daily increasing to 40 mg three times daily)
4/16 (25%) with placebo

Significance not assessed
People with and without risk factors for PTSD after injury were enrolled in the RCT
The RCT may have been underpowered to detect clinically meaningful differences between groups

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

Clinical guide:

There is no evidence from RCTs to support the use of propranolol at present.

Substantive changes

Antihypertensive drugs to prevent PTSD One small RCT added found that the proportion of people with severe injury diagnosed with PTSD at 4 months' follow-up after initial treatment with propranolol for 14 days was the same as that for those given placebo. The RCT was underpowered to detect a clinically meaningful difference. Categorisation unchanged (Unknown effectiveness).

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Hydrocortisone to prevent PTSD

Summary

We don't know whether hydrocortisone is beneficial in preventing PTSD.

Benefits and harms

Hydrocortisone versus saline:

We found no systematic review but found one small RCT comparing intravenous hydrocortisone versus saline.

Incidence of PTSD

Hydrocortisone compared with saline Hydrocortisone may be more effective at reducing the proportion of people diagnosed with PTSD at 31 months in people with septic shock-induced PTSD (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

RCT
20 people in an intensive care unit with septic shock Proportion of people with PTSD (assessed by Structured Clinical Interview using DSM-IV criteria for PTSD) 31 months
1/9 (11%) with intravenous hydrocortisone
7/11 (64%) with saline

RR 0.07
95% CI 0.01 to 0.80
The results of this RCT may not be generalisable to people with trauma not induced by septic shock
Large effect sizeintravenous hydrocortisone

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

Clinical guide:

More research is required before hydrocortisone can be recommended for routine clinical use but these results suggest that further work is indicated.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Multiple-session CBT to prevent PTSD in people with acute stress disorder

Summary

Multiple-session trauma-focused CBT may be effective at preventing development of PTSD in people with psychological distress after a traumatic event.

Benefits and harms

Multiple-session CBT versus supportive counselling (people with acute stress disorder):

We found three RCTs.

Incidence of PTSD

Multiple-session CBT compared with supportive counselling Multiple-session CBT may be more effective at reducing rate of PTSD in people with acute stress disorder, but we don't know whether CBT plus hypnosis is more effective than supportive counselling at reducing rate of PTSD (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

RCT
24 people with acute stress disorder two weeks after a road traffic accident (RTA) or industrial accident Proportion of people who fulfilled diagnostic criteria for PTSD immediately after treatment
8% with five sessions of CBT
83% with five sessions of supportive counselling
Absolute numbers not reported

P <0.001
Effect size not calculatedCBT

RCT
24 people with acute stress disorder two weeks after RTA or industrial accident Proportion of people who fulfilled diagnostic criteria for PTSD 6 months
17% with five sessions of CBT
67% with five sessions of supportive counselling
Absolute numbers not reported

P <0.05
Effect size not calculatedCBT

RCT
3-armed trial
45 people with acute stress disorder two weeks after an RTA or non-sexual assault Proportion of people with PTSD (measured by Clinician Administered PTSD Scale) immediately after treatment
2/14 (14%) with prolonged exposure (five 90-minute sessions)
9/16 (56%) with supportive counselling

P <0.05
Effect size not calculatedCBT

RCT
3-armed trial
45 people with acute stress disorder two weeks after an RTA or non-sexual assault Proportion of people with PTSD (measured by Clinician Administered PTSD Scale) immediately after treatment
3/15 (20%) with prolonged exposure (five 90-minute sessions) plus anxiety management
9/16 (56%) with supportive counselling

P <0.05
Effect size not calculatedCBT

RCT
3-armed trial
45 people with acute stress disorder two weeks after an RTA or non-sexual assault Proportion of people with PTSD (measured by Clinician Administered PTSD Scale) 6 months
2/13 (15%) with prolonged exposure (five 90-minute sessions)
10/15 (67%) with supportive counselling

P <0.05
Effect size not calculatedCBT

RCT
3-armed trial
45 people with acute stress disorder two weeks after an RTA or non-sexual assault Proportion of people with PTSD (measured by Clinician Administered PTSD Scale) 6 months
3/13 (23%) with prolonged exposure (five 90-minute sessions) plus anxiety management
10/15 (67%) with supportive counselling

P <0.05
Effect size not calculatedCBT

RCT
3-armed trial
87 people with acute stress disorder after an RTA or non-sexual assault Proportion of people with PTSD (measured by Clinician Administered PTSD Scale) immediately after completion of treatment
36% with CBT (five 90-minute sessions)
50% with supportive counselling
Absolute numbers not reported

Reported as not significant (reduction in numeric scores was greater in the CBT group)
P value not reported
Not significant

RCT
3-armed trial
87 people with acute stress disorder after an RTA or non-sexual assault Proportion of people with PTSD (measured by Clinician Administered PTSD Scale) immediately after completion of treatment
30% with CBT (five 90-minute sessions) plus hypnosis
50% with supportive counselling
Absolute numbers not reported

Reported as not significant (reduction in numeric scores was greater in the CBT plus hypnosis group)
P value not reported
Not significant

RCT
3-armed trial
87 people with acute stress disorder after an RTA or non-sexual assault Proportion of people with PTSD (measured by Clinician Administered PTSD Scale) 6 months
42% with CBT (five 90-minute sessions)
58% with supportive counselling
Absolute numbers not reported

Reported as not significant (reduction in numeric scores was greater in the CBT group)
P value not reported
Not significant

RCT
3-armed trial
87 people with acute stress disorder after an RTA or non-sexual assault Proportion of people with PTSD (measured by Clinician Administered PTSD Scale) 6 months
40% with CBT (five 90-minute sessions) plus hypnosis
58% with supportive counselling
Absolute numbers not reported

Reported as not significant (reduction in numeric scores was greater in the CBT plus hypnosis group)
P value not reported
Not significant

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

The overall quality of RCTs was poor. Problems included failure to state loss to follow-up, and lack of intention-to-treat analysis despite high withdrawal rates. It is not possible to blind people treated with this type of intervention, but the lack of blinding may affect results.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Multiple-session CBT to prevent PTSD in all people exposed to a traumatic event

Summary

We don't know whether multiple-session trauma-focused CBT is beneficial for people who have experienced a traumatic event but have not been diagnosed with psychological distress.

Benefits and harms

Multiple-session CBT versus no treatment or standard care (all people exposed to a traumatic event):

We found no systematic review, but we found two RCTs.

Incidence of PTSD

Multiple-session CBT compared with no treatment or standard care We don't know whether multiple sessions of CBT are more effective than no treatment or standard care at reducing the proportion of people who meet diagnostic criteria for PTSD at 13 months and in people exposed to a traumatic event (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people developing PTSD

RCT
152 people with psychological distress after physical injury, 116 followed up at 13 months (per protocol analysis) Proportion of people meeting DSM-IV criteria for PTSD 13 months
10/61 (16%) with CBT (4 sessions between 5 and 10 weeks after the injury)
15/55 (27%) with no psychological intervention

RR 0.6
95% CI 0.3 to 1.5
Not significant
Symptoms that may lead to a diagnosis of PTSD

RCT
132 bus drivers who had been attacked in the previous few days Improvement in measures of anxiety (assessed using Horowitz scale; change in mean score from baseline) 6 months
from 7.4 to 6.2 with CBT (1 to 6 sessions)
from 7 to 6.9 with standard care

Significance not assessed

RCT
132 bus drivers who had been attacked in the previous few days Improvement in intrusive symptoms (change in mean score from baseline) 6 months
from 10.9 to 7.7 with CBT (1 to 6 sessions)
from 7.2 to 4.7 with standard care

Significance not assessed

RCT
132 bus drivers who had been attacked in the previous few days Improvement in measures of depression (change in mean score from baseline) 6 months
from 3.6 to 3.2 with CBT (1 to 6 sessions)
from 3.6 to 3.3 with standard care

Significance not assessed

RCT
132 bus drivers who had been attacked in the previous few days Improvement in avoidance symptoms (change in mean score from baseline) 6 months
from 11 to 9.5 with CBT (1 to 6 sessions)
from 8.4 to 7.3 with standard care

Significance not assessed

RCT
152 people with psychological distress after physical injury, 116 followed up at 13 months Mean reduction in severity of PTSD symptom score (assessed using the Impact of Event Scale) 13 months
20.7 with CBT (4 sessions between 5 and 10 weeks after the injury)
11.2 with no psychological intervention

Adjusted mean difference 8.4
95% CI 2.4 to 14.4
Effect size not calculatedCBT

Adverse effects

No data from the following reference on this outcome.

CBT plus education versus no treatment:

We found one RCT comparing three to six sessions of CBT plus educational techniques versus no psychological intervention.

Incidence of PTSD

Multiple-session CBT plus education compared with no treatment We don't know whether multiple sessions of CBT plus education is more effective than no treatment at reducing rates of PTSD at 6 months in people who have experienced a traumatic event (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people who developed PTSD

RCT
151 people who had been involved in a road traffic accident in the past month Rate of PTSD 6 months
with CBT (three to six sessions) plus educational techniques
with no psychological intervention
Absolute results not reported

P = 0.39
The RCT found that people in the treatment group had a significantly higher baseline risk of PTSD compared with the no-intervention group, which makes the results difficult to interpret
Not significant

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

The overall quality of RCTs was poor. Problems included failure to state loss to follow-up, and lack of intention-to-treat analysis despite high withdrawal rates. It is not possible to blind people treated with this type of intervention, but the lack of blinding may affect results.

Clinical guide:

There is some evidence that the provision of trauma-focused CBT for individuals with marked traumatic stress symptoms can be beneficial.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Multiple-session collaborative trauma support to prevent PTSD

Summary

We don't know whether multiple-session collaborative trauma support is beneficial in preventing PTSD.

Benefits and harms

Multiple-session collaborative trauma support versus no treatment/usual care/immediate review:

We found no systematic review but found three RCTs.

Incidence of PTSD

Multiple-session collaborative trauma support compared with no treatment or usual care We don't know whether multiple-session collaborative trauma support is more effective than no treatment or usual care at reducing risk of developing PTSD, reducing poor outcome, or improving PTSD symptoms at 3 to 12 months (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people who developed PTSD

RCT
3-armed trial
70 people who had been admitted to hospital after a road traffic accident (RTA) in the past week Proportion of people with poor outcome (based on traumatic neurosis symptoms)
9/30 (30%) with multiple-session collaborative trauma-support (emotional, practical, and social support for 2–10 hours in the first 3 months)
26/30 (87%) with no intervention

ARR 57%
P <0.001
Effect size not calculatedmultiple-session collaborative trauma support

RCT
3-armed trial
70 people who had been admitted to hospital after a road traffic accident (RTA) in the past week Proportion of people with poor outcome (based on traumatic neurosis symptoms)
9/30 (30%) with multiple-session collaborative trauma-support (emotional, practical, and social support for 2–10 hours in the first 3 months)
6/10 (60%) with immediate review (single-session debriefing)

P <0.05
Effect size not calculatedmultiple-session collaborative trauma support

RCT
120 injured survivors of various physical traumas occurring 24 hours before assessment for eligibility for inclusion Difference in rate of PTSD from baseline (changes in symptoms assessed using the Post-traumatic Stress Disorder Checklist) 12 months
–0.07% with multiple-session collaborative trauma-support
+6% with usual care
Absolute numbers not reported

P = 0.02
Effect size not calculatedmultiple-session collaborative trauma-support

RCT
34 survivors of RTAs or assault in the past 24 hours Proportion of people who developed PTSD (assessed by the Post-traumatic Stress Disorder Checklist) 4 months
17% with multiple-session collaborative trauma-support (emotional, practical, and social support from a trauma support specialist for 4 months)
43% with no intervention
Absolute numbers not reported

P >0.1
The RCT might have lacked power to detect a clinically important difference in outcomes
Not significant

Adverse effects

No data from the following reference on this outcome.

Further information on studies

The overall quality of RCTs was poor. Problems included failure to state loss to follow-up and lack of intention-to-treat analysis despite high withdrawal rates. It is not possible to blind people treated with this type of intervention, but the lack of blinding may affect results. The third RCT carried out a subgroup analysis of the effects of collaborative care on alcohol misuse. It found that collaborative care significantly decreased the rate of alcohol abuse compared with usual care after 12 months (P = 0.48). However, these results should be interpreted with caution because of the methodological problems outlined above.

Comment

Clinical guide:

There is some weak evidence that multiple-session collaborative trauma support may be beneficial. However, more work is required before it can be recommended for routine use.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Multiple-session education to prevent PTSD

Summary

We don't know whether multiple-session education is beneficial in preventing PTSD.

We found no direct information from RCTs about multiple-session education alone compared with no active treatment in people exposed to a traumatic event.

Benefits and harms

Multiple-session education alone:

We found no systematic review or RCTs.

Multiple-session education plus CBT versus no treatment:

See option on multiple-session CBT (all people exposed to a traumatic event).

Further information on studies

None.

Comment

Clinical guide:

There is no evidence from RCTs for the use of multiple-session education alone at present.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Single-session group debriefing to prevent PTSD

Summary

We don't know whether single-session group debriefing is beneficial in preventing PTSD.

We found no direct information from RCTs about single-session group debriefing compared with no active treatment in people exposed to a traumatic event.

Benefits and harms

Group debriefing versus no debriefing:

We found one systematic review (search date 2004). The review identified no RCTs assessing the effects of single-session group debriefing versus no debriefing.

Early versus delayed group debriefing:

We found one systematic review (search date 2004). The review identified one RCT comparing early group debriefing (within 10 hours) versus delayed group debriefing (after 48 hours).

Symptom severity

Early single-session group debriefing compared with delayed single-session group debriefing Early group debriefing (within 10 hours of the traumatic event) may be more effective at reducing the symptoms of PTSD at 2 weeks (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Symptoms of PTSD

Systematic review
77 people
Data from 1 RCT
Severity of PTSD symptoms (mean score on the Post-traumatic Stress Diagnostic Scale; lower score favourable) 2 weeks
6.94 with early group debriefing (within 10 hours)
33.10 with delayed group debriefing (after 48 hours)

P <0.001
Effect size not calculatedearly group debriefing

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

See comment on single-session individual debriefing.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Single-session individual debriefing to prevent PTSD

Summary

Single-session individual debriefing may increase the rate of PTSD after a traumatic event compared with no debriefing.

Benefits and harms

Individual debriefing versus no debriefing:

We found one systematic review (search date 2004, 5 RCTs, 356 people).

Incidence of PTSD

Individual debriefing compared with no debriefing Single-session individual psychological debriefing seems no more effective than no debriefing at reducing rate of PTSD in the shorter term (3–6 months) and may be less effective at reducing rate of PTSD at 13 months (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Rate of PTSD

Systematic review
238 people
2 RCTs in this analysis
Rate of PTSD 3 to 6 months
with single-session individual psychological debriefing
with no debriefing
Absolute results not reported

RR 1.2
95% CI 0.84 to 1.71
Not significant

Systematic review
133 people
Data from 1 RCT
Rate of PTSD 13 months
with single-session individual psychological debriefing
with no debriefing
Absolute results not reported

RR 1.87, 95% CI 1.12 to 3.12
Small effect sizeno debriefing

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
Adverse effects
with single-session individual psychological debriefing
with no debriefing

Further information on studies

None.

Comment

The overall quality of RCTs was moderate. Methodological problems included failure to state loss to follow-up, lack of intention-to-treat analysis, and high withdrawal rates. It is not possible to blind people treated with this type of intervention, but the lack of blinding may affect results.

Clinical guide:

It seems that single-session debriefing is not beneficial in preventing PTSD.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Supportive counselling to prevent PTSD

Summary

Supportive counselling may be less effective than multiple-session CBT at preventing onset of PTSD.

We found no direct information from RCTs about supportive counselling compared with no active treatment in people exposed to a traumatic event.

Benefits and harms

Supportive counselling versus no treatment:

We found no systematic review or RCTs comparing supportive counselling versus no treatment.

Supportive counselling versus multiple-session CBT:

See option on multiple-session CBT in people with acute stress disorder.

Further information on studies

None.

Comment

Clinical guide:

There is currently no evidence from RCTs for the use of supportive counselling.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Temazepam to prevent PTSD

Summary

We don't know whether temazepam is beneficial in preventing PTSD.

Benefits and harms

Temazepam versus placebo:

We found no systematic review, but found one RCT comparing temazepam versus placebo.

Incidence of PTSD

Temazepam compared with placebo We don't know whether temazepam is more effective than placebo at reducing the proportion of people with PTSD at 6 weeks in people with acute stress disorder or early symptoms of PTSD (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people who developed PTSD

RCT
22 people with PTSD symptoms and sleep-initiation difficulties a mean 14 days after a road traffic accident, industrial accident, or non-sexual assault, seven with acute stress disorder Proportion of people with PTSD (assessed by Structured Clinical Interview using DSM-IV criteria for PTSD) 6 weeks
6/11 (54%) with temazepam (30 mg daily for 5 days followed by 15 mg daily for 2 days)
3/11 (27%) with placebo

P value not reported
The RCT is likely to have been underpowered to detect clinically important differences in outcomes

Adverse effects

No data from the following reference on this outcome.

Further information on studies

The RCT found that temazepam significantly improved sleep after one night compared with placebo (P <0.04), but found similar total sleep patterns after 1 week (P value not reported).

Comment

The RCT was published as a letter to the editor.

Clinical guide:

There is no evidence from RCTs to support the use of temazepam at present.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Affect management to treat PTSD

Summary

We don't know whether affect management is beneficial in people with PTSD.

Benefits and harms

Affect management versus waiting list control:

We found no systematic review, but found one RCT comparing 15 weeks of versus waiting list control.

Symptom severity

Affect management compared with waiting list control Affect management plus drug treatment may be more effective at reducing symptom severity of PTSD at 15 weeks (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

RCT
48 women with PTSD related to childhood sexual abuse Improvement in PTSD symptoms (assessed by the Davidson Trauma Scale; mean change from baseline) 15 weeks
45.8 with affect management treatment (in addition to drug treatment) for 15 weeks
73.1 with waiting list control

P = 0.02
Effect size not calculatedaffect management
Dissociative symptoms

RCT
48 women with PTSD related to childhood sexual abuse Improvement in dissociative symptoms (assessed by the Dissociative Experiences Scale; mean change from baseline) 15 weeks
11.9 with affect management treatment (in addition to drug treatment) for 15 weeks
25.2 with waiting list control

P = 0.02
Effect size not calculatedaffect management

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

Clinical guide:

There is some evidence for the use of affect management, but further studies are needed.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Antiepileptic drugs to treat PTSD

Summary

We don't know whether antiepileptic drugs are beneficial in people with PTSD.

Benefits and harms

Antiepileptic drugs versus placebo:

We found no systematic review but found two RCTs.

Symptom severity

Antiepileptic drugs compared with placebo Antiepileptic drugs (topiramate and tiagabine) seem no more effective than placebo at reducing the severity of symptoms of PTSD at 12 weeks in people with non-combat-related traumatic events (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

RCT
38 people with chronic PTSD resulting from various non-combat-related traumatic events Change in PTSD symptoms (mean change in Clinician Administered PTSD Scale) 12 weeks (end of treatment)
–52.7 with topiramate (flexible dose: 25–400 mg/day)
–42.0 with placebo

P = 0.23
Not significant

RCT
232 people with PTSD resulting from various non-combat-related traumatic events Change in PTSD symptoms (mean change in Clinician Administered PTSD Scale) 12 weeks (end of treatment)
–30.7 with tiagabine (flexible dose: 4–16 mg/day)
–30.2 with placebo

P = 0.85
Not significant

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
38 people with chronic PTSD resulting from various non-combat-related traumatic events Proportion of people withdrawing owing to adverse effects
4/19 (21%) with topiramate (flexible dose: 25–400 mg/day)
3/19 (16%) with placebo

Significance not assessed

RCT
38 people with chronic PTSD resulting from various non-combat-related traumatic events Proportion of people with headache
7/19 (37%) with topiramate (flexible dose: 25–400 mg/day)
5/19 (26%) with placebo

Significance not assessed

RCT
38 people with chronic PTSD resulting from various non-combat-related traumatic events Proportion of people with sinusitis
5/19 (26%) with topiramate (flexible dose: 25–400 mg/day)
2/19 (11%) with placebo

Significance not assessed

RCT
38 people with chronic PTSD resulting from various non-combat-related traumatic events Proportion of people with taste perversion
5/19 (26%) with topiramate (flexible dose: 25–400 mg/day)
0/19 (0%) with placebo

Significance not assessed

RCT
232 people with PTSD resulting from various non-combat-related traumatic events Proportion of people with dizziness
32% with tiagabine (flexible dose: 4–16 mg/day)
13% with placebo
Absolute numbers not reported

Significance not assessed

RCT
232 people with PTSD resulting from various non-combat-related traumatic events Proportion of people with headache
25% with tiagabine (flexible dose: 4–16 mg/day)
27% with placebo
Absolute numbers not reported

Significance not assessed

RCT
232 people with PTSD resulting from various non-combat-related traumatic events Proportion of people with somnolence
20% with tiagabine (flexible dose: 4–16 mg/day)
10% with placebo
Absolute numbers not reported

Significance not assessed

Further information on studies

None.

Comment

None.

Substantive changes

Antiepileptic drugs to treat PTSD Two RCTs added assessing the effects of topiramate and tiagabine found no significant difference between the antiepileptic drugs assessed and placebo in PTSD symptoms at the end of treatment. Categorisation unchanged (Unknown effectiveness).

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Antihypertensive drugs to treat PTSD

Summary

We don't know whether antihypertensive drugs are beneficial in people with PTSD.

We found no clinically important results from RCTs about the effects of antihypertensive drugs as treatments in people with PTSD.

Benefits and harms

Antihypertensive drugs:

We found no systematic review or RCTs of antihypertensive drugs as treatments in people with PTSD.

Further information on studies

None.

Comment

None.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Benzodiazepines to treat PTSD

Summary

We found insufficient good evidence to assess the effects of benzodiazepines.

We found no clinically important results from RCTs about the effects of benzodiazepines in people with PTSD.

Benefits and harms

Benzodiazepines:

We found one systematic review (search date 2004), which identified no RCTs of sufficient quality on the effects of benzodiazepines in people with PTSD.

Further information on studies

None.

Comment

Clinical guide:

There is no evidence from RCTs to support the use of benzodiazepines at present.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Brofaromine to treat PTSD

Summary

We don't know whether brofaromine is beneficial in people with PTSD.

MAOIs may require dietary restriction and can precipitate a hypertensive crisis.

Benefits and harms

Brofaromine versus placebo:

We found one systematic review (search date 2004, 1 RCT, 45 people).

Symptom severity

Brofaromine compared with placebo We don't know whether brofaromine (a monoamine oxidase inhibitor [MAOI]) is more effective at reducing the severity of symptoms of PTSD (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

Systematic review
45 people
Data from 1 RCT
Severity of self-reported PTSD symptoms 8 weeks
with brofaromine
with placebo
Absolute results not reported

SMD –0.58
95% CI –1.18 to +0.02
Not significant

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
66 people
Data from 1 RCT
Proportion of people withdrawing from RCT 12 weeks
with brofaromine
with placebo
Absolute results not reported

RR 1.44
95% CI 0.69 to 3.01
No other information on adverse effects given
Not significant

Further information on studies

None.

Comment

Brofaromine, an MAOI, has not been marketed in the UK.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

CBT to treat PTSD

Summary

In people with PTSD, trauma-focused CBT improves PTSD symptoms compared with no treatment or with other psychological interventions, including stress management and present-centred therapy.

Benefits and harms

CBT versus no treatment or usual care:

We found one systematic review (search date 2004, 24 RCTs, total number of people not reported) and nine subsequent RCTs.

Symptom severity

Individual CBT compared with no treatment Individual CBT is more effective at reducing the severity of PTSD symptoms after 1–14 sessions (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

RCT
59 people with PTSD after an earthquake Change in Clinician Administered PTSD Scale (mean score at baseline and at follow-up) 6 weeks
from 67.8 to 44.4 with CBT (single 60-minute session)
from 60.5 to 54.7 with no treatment

P <0.001
Effect size not calculatedCBT

RCT
3-armed trial
74 women with PTSD related to childhood sexual abuse Change in Clinician Administered PTSD Scale (mean score at baseline and after therapy) 14 weeks
from 69.9 to 53.1 with CBT (14 sessions lasting 90–120 minutes)
from 72.0 to 65.5 with no treatment

Significance not assessed

RCT
3-armed trial
171 female survivors of assault and who had PTSD Change in PTSD symptom scale interview score (mean score at baseline and after treatment)
from 35.1 to 19.0 with prolonged exposure (9–12 sessions of 90–120 minutes' duration)
from 35.5 to 29.4 with no treatment

P <0.001
Effect size not calculatedCBT

RCT
3-armed trial
171 female survivors of assault and who had PTSD Change in PTSD symptom scale interview (mean score at baseline and after treatment)
from 30.0 to 17.1 with prolonged exposure/cognitive restructuring (9–12 sessions of 90–120 minutes' duration)
from 35.5 to 29.4 with no treatment

P <0.001
Effect size not calculatedCBT

RCT
Crossover design
40 Cambodian refugees with treatment-resistant PTSD and panic attacks Change in Clinician Administered PTSD scale (mean score at baseline and after treatment) cessation of treatment
from 74.9 to 39.3 with CBT (12 weekly sessions)
from 75.9 to 73.1 with no treatment

P <0.001
Effect size not calculatedCBT

RCT
60 US veterans with chronic military-related PTSD Change in Clinician Administered PTSD scale 10 weeks
with cognitive processing therapy (12 bi-weekly sessions)
with no treatment
Absolute results not reported

Regression analysis for reduction in Clinician administered PTSD scale
P <0.01
Effect size not calculatedCBT

RCT
42 people with chronic (20 people) or severe (22 people) subsyndromal PTSD after a motor vehicle accident Change in Clinician Administered PTSD scale (mean score at baseline and follow-up) 12 weeks after cessation of treatment
from 47.6 to 18.3 with cognitive processing therapy (8–12 sessions)
from 41.8 to 35.2 with no treatment

P <0.001
Effect size not calculatedCBT

RCT
31 people with chronic PTSD after an earthquake Change in Clinician Administered PTSD scale (mean score at baseline and follow-up) 8 weeks after cessation of treatment
from 63.1 to 30.2 with single-session of CBT (exposure to simulated earth tremors supplemented with instructions on self-exposure)
from 62.3 to 49.1 with no treatment

P <0.01
Effect size not calculatedCBT

RCT
58 people with chronic PTSD related to terrorism and civil conflict Self-reported Post-Traumatic Stress Diagnostic Scale 12 weeks (end of treatment)
with CBT (up to 12 sessions)
with no treatment
Absolute results not reported

Mean difference between groups 9.6
95% CI 3.6 to 15.6
Effect size not calculatedCBT

RCT
28 people with PTSD related to discrete traumatic events in adulthood Change in frequency component of the Clinician Administered PTSD scale (mean score at baseline and at end of treatment) end of treatment
from 42.0 to 16.0 with CBT (up to 12 sessions of cognitive therapy)
from 31.6 to 35.5 with no treatment

P <0.0005
The RCT reported a significant difference in baseline Clinician Administered PTSD scale scores between the two groups (reported as significant; P value not reported)
Effect size not calculatedCBT

RCT
28 people with PTSD related to discrete traumatic events in adulthood Change in intensity component of the Clinician Administered PTSD scale (mean score at baseline and at end of treatment) end of treatment
from 36.5 to 13.7 with CBT (up to 12 sessions of cognitive therapy)
from 29.0 to 30.9 with no treatment

P <0.0005
The RCT reported a significant difference in baseline Clinician Administered PTSD scale scores between the two groups (reported as significant; P value not reported)
Effect size not calculatedCBT

Incidence of PTSD

Individual CBT compared with no treatment Individual CBT is more effective at reducing the proportion of people meeting diagnostic criteria for PTSD after 1–14 sessions (high-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

Systematic review
716 people
14 RCTs in this analysis
Proportion of people meeting diagnostic criteria for PTSD
186/435 (43%) with trauma-focused CBT
249/281 (89%) with waiting list control and usual care

RR 0.47
95% CI 0.37 to 0.59
Moderate effect sizetrauma-focused CBT

RCT
28 people with PTSD related to discrete traumatic events in adulthood Proportion of people no longer meeting diagnostic criteria for PTSD end of treatment
10/14 (71%) with CBT (up to 12 sessions of cognitive therapy)
0/14 (0%) with no treatment

P <0.005
The RCT reported a significant difference in baseline Clinician Administered PTSD scale scores between the two groups (reported as significant; P value not reported)
Effect size not calculatedCBT

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
814 people
14 RCTs in this analysis
Proportion of people withdrawing for any reason
107/483 (22%) with trauma-focused CBT
50/331 (15%) with waiting list control and usual care

RR 1.47
95% CI 1.07 to 2.02
Small effect sizeusual care or waiting list control

RCT
3-armed trial
74 women with PTSD related to childhood sexual abuse Proportion of people withdrawing (no details given on reasons for withdrawal) 14 weeks
12/29 (41%) with CBT (14 sessions lasting 90–120 minutes)
3/23 (13%) with no treatment

Significance not assessed

No data from the following reference on this outcome.

CBT versus present-centred therapy:

We found two RCTs.

Symptom severity

CBT compared with present-centred therapy We don't know whether CBT is more effective than present-centred therapy at reducing the severity of PTSD symptoms in women with PTSD related to childhood sexual abuse or to military active service (low-quality evidence)

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

RCT
3-armed trial
74 women with PTSD related to childhood sexual abuse Change in Clinician Administered PTSD Scale (mean score before and after treatment) 14 weeks
from 69.9 to 53.1 with CBT (14 sessions lasting 90–120 minutes)
from 67.7 to 47.2 with present-centred therapy (14 sessions lasting 90–120 minutes)

Significance not assessed

RCT
284 women with PTSD; 277 veterans and 7 active-service personnel Change in Clinician Administered PTSD Scale (mean score before and after treatment) immediately after treatment
from 77.6 to 52.9 with CBT (10 weekly sessions of prolonged exposure lasting 90 minutes)
from 77.9 to 60.1 with present-centred therapy (10 weekly sessions lasting 90 minutes)

P <0.05
Effect size not calculatedCBT

RCT
284 women with PTSD; 277 veterans and 7 active-service personnel Change in Clinician Administered PTSD Scale (mean score before and after treatment) 3 months
from 77.6 to 49.7 with CBT (10 weekly sessions of prolonged exposure lasting 90 minutes)
from 77.9 to 56.0 with present-centred therapy (10 weekly sessions lasting 90 minutes)

P <0.05
Effect size not calculatedCBT

RCT
284 women with PTSD; 277 veterans and 7 active-service personnel Change in Clinician Administered PTSD Scale (mean score before and after treatment) 6 months
from 77.6 to 50.4 with CBT (10 weekly sessions of prolonged exposure lasting 90 minutes)
from 77.9 to 54.5 with present-centred therapy (10 weekly sessions lasting 90 minutes)

Reported as not significant
P value not reported
Not significant

Incidence of PTSD

CBT compared with present-centred therapy CBT is more effective at reducing the proportion of women meeting diagnostic criteria for PTSD in women with PTSD related to military active service (high-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

RCT
284 women with PTSD; 277 veterans and 7 active-service personnel Proportion of women no longer meeting diagnostic criteria for PTSD immediately after treatment
55/141 (39%) with CBT (10 weekly sessions of prolonged exposure lasting 90 minutes)
29/143 (20%) with present-centred therapy (10 weekly sessions lasting 90 minutes)

P = 0.002
Effect size not calculatedCBT

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
3-armed trial
74 women with PTSD related to childhood sexual abuse Proportion of people withdrawing (no details given on reasons for withdrawal)
12/29 (41%) with CBT (14 sessions lasting 90–120 minutes)
2/22 (9%) with present-centred therapy (14 sessions lasting 90–120 minutes)

Significance not assessed

RCT
284 women with PTSD; 277 veterans and 7 active-service personnel Proportion of people withdrawing (no details given on reasons for withdrawal)
53/141 (38%) with CBT (10 weekly sessions of prolonged exposure lasting 90 minutes)
30/143 (21%) with present-centred therapy (10 weekly sessions lasting 90 minutes)

P = 0.002
Effect size not calculatedpresent-centred therapy

CBT versus stress management:

We found one systematic review (search date 2004, 24 RCTs, total number of people not reported).

Incidence of PTSD

CBT compared with stress management CBT is more effective at reducing the proportion of people meeting diagnostic criteria for PTSD (high-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

Systematic review
284 people
6 RCTs in this analysis
Proportion of people with a diagnosis of PTSD
81/180 (45%) with trauma-focused CBT
62/104 (60%) with stress management

RR 0.78
95% CI 0.61 to 0.99
Small effect sizetrauma-focused CBT

Symptom severity

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
284 people
6 RCTs in this analysis
Proportion of people withdrawing (any reason)
32/180 (18%) with trauma-focused CBT
17/104 (16%) with stress management

RR 1.17
95% CI 0.69 to 2.00
Not significant

CBT versus supportive psychotherapy, psychodynamic psychotherapy, or hypnotherapy:

We found one systematic review (search date 2004, 24 RCTs, total number of people not reported).

Incidence of PTSD

CBT compared with supportive psychotherapy, psychodynamic psychotherapy, or hypnotherapy CBT seems more effective at reducing the rate of PTSD (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

Systematic review
286 people
5 RCTs in this analysis
Proportion of people with a diagnosis of PTSD
59/136 (43%) with trauma-focused CBT
88/150 (59%) with supportive psychotherapy, psychodynamic psychotherapy, and hypnotherapy (combined analysis)

RR 0.71
95% CI 0.56 to 0.89
Small effect sizetrauma-focused CBT

Symptom severity

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects (any)

Systematic review
290 people
5 RCTs in this analysis
Proportion of people withdrawing (any reason)
28/138 (20%) with trauma-focused CBT
24/152 (16%) with supportive psychotherapy, psychodynamic psychotherapy, and hypnotherapy (combined analysis)

RR 1.14, 95% CI 0.68 to 1.90
Not significant

CBT versus supportive psychotherapy alone:

See option on supportive psychotherapy.

CBT versus eye movement desensitisation and reprocessing:

See option on eye movement desensitisation and reprocessing.

Further information on studies

None.

Comment

Clinical guide:

The higher rate of withdrawal in the CBT group (compared with no treatment) noted by the review raises questions regarding tolerability that require further investigation, not least because there have been case reports of worsening symptoms in some people receiving imaginal flooding. There is good evidence from RCTs for the use of individual trauma-focused CBT as a first-line treatment for PTSD.

Substantive changes

CBT to treat PTSD Three RCTs added, which found that CBT improved PTSD symptoms compared with no treatment. One RCT added comparing CBT (prolonged exposure) versus present-centred therapy found greater improvements in PTSD symptoms immediately after treatment and at 3 months' follow-up with CBT. However, there was no significant difference between groups in PTSD symptoms at 6 months. The proportion of women no longer meeting diagnostic criteria for PTSD was larger immediately after treatment with CBT than with present-centred therapy. Categorisation unchanged (Beneficial).

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Drama therapy to treat PTSD

Summary

We don't know whether drama therapy is beneficial in people with PTSD.

We found no clinically important results from RCTs about the effects of drama therapy in improving symptoms of PTSD.

Benefits and harms

Drama therapy:

We found no systematic review or RCTs on drama therapy in people with PTSD.

Further information on studies

None.

Comment

Clinical guide:

There is no evidence from RCTs for the use of drama therapy at present.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Eye movement desensitisation and reprocessing to treat PTSD

Summary

Eye movement desensitisation and reprocessing seems as effective as trauma-focused CBT in the treatment of chronic PTSD.

Benefits and harms

Eye movement desensitisation and reprocessing (EMDR) versus no treatment or usual care:

We found one systematic review (search date 2004, 11 RCTs, total number of people not reported), and one subsequent RCT.

Incidence of PTSD

Eye movement desensitisation and reprocessing (EMDR) compared with no treatment or usual care EMDR may be more effective at reducing the rate of PTSD (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

Systematic review
169 people
5 RCTs in this analysis
Proportion of people with diagnosis of PTSD
47/87 (54%) with EMDR
79/82 (96%) with waiting list control or usual care (combined analysis)

RR 0.51
95% CI 0.28 to 0.95
Small effect sizeEMDR

RCT
24 public transport workers with work-related chronic PTSD; people had been assaulted at work or had experienced a person-under-a-train accident Proportion of people no longer meeting diagnostic criteria for PTSD
8/12 (67%) with EMDR (five sessions of 90 minutes' duration during a 2-month period)
1/9 (11%) with waiting list control

P = 0.02
Effect size not calculatedEMDR

Symptom severity

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
168 people
5 RCTs in this analysis
Proportion of people withdrawing for any reason
17/88 (19%) with EMDR
11/80 (14%) with waiting list control or usual care (combined analysis)

RR 1.28
95% CI 0.64 to 2.56
Not significant

No data from the following reference on this outcome.

EMDR versus stress management:

We found one systematic review (search date 2004, 11 RCTs, total number of people not reported).

Incidence of PTSD

EMDR compared with stress management EMDR and stress management seem equally effective at reducing the proportion of people with PTSD (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

Systematic review
84 people
3 RCTs in this analysis
Proportion of people with diagnosis of PTSD
19/41 (46%) with EMDR
29/43 (67%) with stress management

RR 0.69, 95% CI 0.46 to 1.04
Not significant

Symptom severity

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
84 people
3 RCTs in this analysis
Proportion of people withdrawing for any reason
6/41 (15%) with EMDR
6/43 (14%) with stress management

RR 1.03
95% CI 0.37 to 2.88
Not significant

EMDR versus CBT:

We found one systematic review (search date 2004, 11 RCTs, total number of people not reported).

Incidence of PTSD

EMDR compared with CBT EMDR and CBT are equally effective at reducing the rate of PTSD (high-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

Systematic review
220 people
6 RCTs in this analysis
Proportion of people with diagnosis of PTSD
56/109 (51%) with EMDR
60/111 (54%) with trauma-focused CBT

RR 1.03, 95% CI 0.64 to 1.66
Not significant

Symptom severity

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
240 people
7 RCTs in this analysis
Proportion of people withdrawing for any reason
29/119 (24%) with EMDR
35/121 (29%) with trauma-focused CBT

RR 0.83
95% CI 0.54 to 1.27
Not significant

EMDR versus fluoxetine:

We found one RCT comparing three interventions: EMDR, fluoxetine 10–60 mg/day, or placebo over 8 weeks.

Symptom severity

EMDR compared with fluoxetine We don't know whether EMDR is more effective than fluoxetine at reducing severity of symptoms of PTSD (symptom score and cure rate) at 8 weeks. However, EMDR may be more effective than fluoxetine at maintaining any improvement in symptoms (symptom score) at 6 months (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

RCT
3-armed trial
88 people with chronic PTSD resulting from various traumatic events Change in Clinician Administered PTSD Scale (mean score before and after treatment) 8 weeks (end of treatment)
from 69.4 to 32.55 with EMDR
from 73.7 to 42.67 with fluoxetine 10–60 mg/day

P = 0.13
The RCT reported that all people randomised had intense exposure treatment (2 personalised trauma manuscripts), which may have contributed to the improvements seen in both groups
Not significant

RCT
3-armed trial
88 people with chronic PTSD resulting from various traumatic events Change in Clinician Administered PTSD Scale (mean score before and after treatment) 6 months
from 71.7 to 25.79 with EMDR
from 75.9 to 42.12 with fluoxetine 10–60 mg/day

P = 0.005
The RCT reported that all people randomised had intense exposure treatment (2 personalised trauma manuscripts), which may have contributed to the improvements seen in both groups
Effect size not calculatedEMDR

Incidence of PTSD

EMDR compared with fluoxetine EMDR and fluoxetine may be equally effective at reducing the proportion of people with a diagnosis of PTSD at 8 weeks and 6 months (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

RCT
3-armed trial
88 people with chronic PTSD resulting from various traumatic events Proportion of people no longer meeting diagnostic criteria for PTSD 8 weeks (end of treatment)
76% with EMDR
73% with fluoxetine 10–60 mg/day
Absolute numbers not reported

P = 0.82
The RCT reported that all people randomised had intense exposure treatment (2 personalised trauma manuscripts), which may have contributed to the improvements seen in both groups
Not significant

RCT
3-armed trial
88 people with chronic PTSD resulting from various traumatic events Proportion of people no longer meeting diagnostic criteria for PTSD 6 months
88% with EMDR
73% with fluoxetine 10–60 mg/day
Absolute numbers not reported

P = 0.20
The RCT reported that all people randomised had intense exposure treatment (2 personalised trauma manuscripts), which may have contributed to the improvements seen in both groups
Not significant

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

Clinical guide:

There is good evidence from RCTs for the use of EMDR as a first-line treatment for PTSD.

Substantive changes

Eye movement desensitisation and reprocessing to treat PTSD One small RCT added found that eye movement desensitisation and reprocessing (EMDR) improved symptoms of PTSD and reduced the proportion of people fulfilling criteria for PTSD compared with no treatment. One RCT comparing EMDR versus fluoxetine found no significant difference between treatments in PTSD symptoms at the end of treatment. However, EMDR was found to be more effective at sustaining improvement in symptoms at 6 months compared with fluoxetine. Categorisation unchanged (Beneficial).

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Fluoxetine (selective serotonin reuptake inhibitor) to treat PTSD

Summary

The benefits of fluoxetine are unclear.

SSRIs cause adverse effects including nausea and headache, and have been associated with an increased risk of self-harm in adults.

Benefits and harms

Fluoxetine versus placebo:

We found one systematic review (search date 2004, 5 RCTs, total number of people not reported) and two subsequent RCTs.

Symptom severity

Fluoxetine compared with placebo We don't know whether fluoxetine is more effective at reducing symptom severity of PTSD (symptom score and cure rate) at 8 to 12 weeks (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

Systematic review
301 people
Data from 1 RCT
Severity of clinician-rated PTSD symptoms 12 weeks
with fluoxetine
with placebo
Absolute results not reported

SMD –0.28
95% CI –0.54 to –0.02
Effect size not calculatedfluoxetine

RCT
3-armed trial
88 people with chronic PTSD resulting from various traumatic events Change in Clinician Administered PTSD Scale (mean score before and after treatment) 8 weeks (end of treatment)
from 73.7 to 42.67 with fluoxetine 10–60 mg/day
from 70.3 to 43.55 with placebo

P = 0.61
The RCT reported that all people randomised had intense exposure treatment (2 personalised trauma manuscripts), which may have contributed to the improvements seen in both groups
Not significant

RCT
3-armed trial
411 people with chronic PTSD resulting from various traumatic events Mean change in Clinician Administered PTSD Scale 12 weeks (end of treatment)
–42.9 with fluoxetine 20 mg daily (fixed dose)
–42.8 with fluoxetine 40 mg/daily (fixed dose)
–36.6 with placebo

P = 0.151
P value for comparison among all three groups; statistical assessments for between-group comparisons of fluoxetine versus placebo not carried out
The number of people who withdrew from the RCT is unclear
Not significant

Incidence of PTSD

fluoxetine compared with placebo We don't know whether fluoxetine is more effective at reducing proportion of people no longer meeting diagnostic criteria for PTSD at 8 weeks (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

RCT
3-armed trial
88 people with chronic PTSD resulting from various traumatic events Proportion of people no longer meeting diagnostic criteria for PTSD 8 weeks (end of treatment)
73% with fluoxetine 10–60 mg/day
59% with placebo
Absolute numbers not reported

P = 0.23
The RCT reported that all people randomised had intense exposure treatment (2 personalised trauma manuscripts), which may have contributed to the improvements seen in both groups
Not significant

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
66 people
2 RCTs in this analysis
Proportion of people withdrawing (any reason)
7/33 (21%) with fluoxetine
12/33 (36%) with placebo

RR 0.60
95% CI 0.28 to 1.30
Not significant

RCT
65 people
In review
Nausea
with fluoxetine
with placebo
Absolute results not reported

P <0.05
Effect size not calculatedplacebo

RCT
65 people
In review
Diarrhoea
with fluoxetine
with placebo
Absolute results not reported

P <0.05
Effect size not calculatedplacebo

RCT
65 people
In review
Thirst
with fluoxetine
with placebo
Absolute results not reported

P <0.05
Effect size not calculatedplacebo

RCT
3-armed trial
411 people with chronic PTSD resulting from various traumatic events Proportion of people withdrawing due to adverse effects 12 weeks (end of treatment)
4% with fluoxetine 20 mg daily (fixed dose)
13% with fluoxetine 40 mg daily (fixed dose)
8% with placebo
Absolute numbers not reported

P greater than 0.20 for both comparisons of fluoxetine versus placebo
The number of people who withdrew from the RCT is unclear
Not significant

No data from the following reference on this outcome.

Fluoxetine versus eye movement desensitisation and reprocessing (EMDR):

See option on EMDR.

Further information on studies

None.

Comment

All antidepressants have been associated with increased risk of suicidal thinking and behaviour in young adults aged 18 to 24 years (see harms of prescription antidepressant drugs in review on depression in adults [drug and other physical treatments]). There is limited robust evidence available to examine the link between SSRIs and increased risk of self-harm or suicide in adults and, in light of this, practitioners should be guided by the recommendations and warnings issued by their national drug regulatory authorities with respect to the prescribing of antidepressants, particularly in children and adolescents (see review on depression in children and adolescents).

We found one RCT (62 people treated for PTSD for 6 months) assessing the effects of fluoxetine on relapse rates. The RCT found that fluoxetine for 6 months resulted in significantly fewer relapses than placebo for 6 months (22% with fluoxetine v 50% with placebo; P = 0.02). It has been noted that the placebo response in RCTs in PTSD can be high, which is likely to affect interpretation of the results.

Substantive changes

Fluoxetine to treat PTSD Two RCTs added found no significant difference between fluoxetine and placebo in PTSD symptoms at the end of treatment (8–12 weeks). One of the RCTs also found no significant difference between fluoxetine and placebo in the proportion of people no longer meeting diagnostic criteria for PTSD at the end of treatment. One RCT compared fluoxetine versus eye movement desensitisation and reprocessing (EMDR). It found no significant difference between treatments in PTSD symptoms at the end of treatment. However, EMDR was found to be more effective at sustaining improvement in symptoms at 6 months compared with fluoxetine. Evidence added at update suggests effects of fluoxetine in treating PTSD are unclear. Categorisation changed (from Likely to be beneficial to Unknown effectiveness).

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Group therapy to treat PTSD

Summary

We don't know whether group therapy is beneficial in people with PTSD.

Benefits and harms

Group CBT versus no treatment or usual care:

We found one systematic review (search date 2004, 4 RCTs, total number of people not reported).

Incidence of PTSD

CBT compared with waiting list control We don't know whether group CBT is more effective than waiting list control and usual care at reducing the rate of PTSD (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

Systematic review
48 people
Data from 1 RCT
Proportion of people meeting diagnostic criteria for PTSD
9/24 (38%) with group CBT
16/24 (67%) with waiting list control and usual care (combined analysis)

RR 0.56
95% CI 0.31 to 1.01
Not significant

Symptom severity

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Group CBT versus present-centred therapy:

We found one systematic review (search date 2004, 4 RCTs, total number of people not reported).

Incidence of PTSD

Group CBT compared with present-centred group therapy Trauma-focused group therapy and present-focused group therapy are equally effective at reducing the rate of PTSD (high-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

Systematic review
360 people
Data from 1 RCT
Proportion of people meeting diagnostic criteria for PTSD
110/180 (61%) with trauma-focused group therapy
112/180 (62%) with present-focused group therapy

RR 0.98
95% CI 0.83 to 1.16
Not significant

Symptom severity

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Group CBT plus individual CBT versus no treatment:

We found one RCT.

Symptom severity

Group plus individual CBT compared with no treatment Group plus individual CBT seems more effective at reducing severity of symptoms of PTSD (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

RCT
71 women with PTSD after sexual abuse Change in Clinician Administered PTSD Scale (mean score before and after treatment) frame
from 65.5 to 9 with group CBT plus individual CBT
from 68.3 to 63 with no treatment

P <0.001
Effect size not calculatedgroup CBT plus individual CBT

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

Clinical guide:

There is limited evidence for the use of group therapy alone at present. It was found to be more effective when combined with individual CBT, but it is not clear how much the group therapy contributed to the overall effect.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Hypnotherapy to treat PTSD

Summary

We don't know whether hypnotherapy is beneficial in people with PTSD.

Benefits and harms

Hypnotherapy versus waiting list control:

We found one systematic review (search date 2004), which identified one four-arm RCT.

Symptom severity

Hypnotherapy compared with waiting list control Hypnotherapy may be more effective at reducing PTSD symptom severity (intrusion/avoidance) at 4 months (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Intrusion/avoidance symptoms

RCT
4-armed trial
112 people
In review
Improvement in intrusion and avoidance symptom score (change from baseline) 4 months
19.1 with hypnotherapy
4.6 with waiting list control

P <0.05
Effect size not calculatedhypnotherapy

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

Clinical guide:

There is no good evidence from RCTs for the use of hypnotherapy at present.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Inpatient treatment programmes to treat PTSD

Summary

We don't know whether inpatient treatment regimens are beneficial in people with PTSD.

We found no clinically important results from RCTs about the effects of inpatient treatment programmes in improving symptoms of PTSD.

Benefits and harms

Inpatient treatment programmes:

We found no systematic review or RCTs on inpatient treatment programmes in people with PTSD.

Further information on studies

None.

Comment

Clinical guide:

There is no evidence from RCTs for the use of inpatient treatment programmes at present.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Internet-based psychotherapy to treat PTSD

Summary

We don't know whether Internet-based psychotherapy is beneficial in people with PTSD.

Benefits and harms

Internet-based psychotherapy versus waiting list control:

We found no systematic review but found one RCT that compared Internet-based psychotherapy versus waiting list control for 5 weeks.

Symptom severity

Internet-based psychotherapy compared with waiting list control Internet-based psychotherapy may be more effective at reducing PTSD symptom severity (intrusion/avoidance) at 5 weeks (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Intrusion/avoidance symptoms

RCT
25 people Mean reduction in intrusive symptom score (change from baseline) 5 weeks
11.0 with Internet-based psychotherapy
3.6 with waiting list control

P <0.04
Effect size not calculatedInternet-based psychotherapy

RCT
25 people Mean reduction in avoidance symptom score (change from baseline) 5 weeks
9.6 with Internet-based psychotherapy
2.9 with waiting list control

P <0.03
Effect size not calculatedInternet-based psychotherapy

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

Clinical guide:

There is some evidence from one small RCT that Internet-based psychotherapy may be effective. More studies are required.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Mirtazapine to treat PTSD

Summary

We don't know whether mirtazapine is beneficial in people with PTSD.

SSRIs cause adverse effects including nausea and headache, and have been associated with an increased risk of self-harm in adults.

Benefits and harms

Mirtazapine versus placebo:

We found one systematic review (search date 2004, 1 RCT, 29 people).

Symptom severity

Compared with placebo Mirtazapine may be more effective at reducing the severity of symptoms of PTSD (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

Systematic review
29 people
Data from 1 RCT
Severity of clinician-rated PTSD symptoms
with mirtazapine
with placebo
Absolute results not reported

SMD –1.89
95% CI –3.00 to –0.78
The results of this RCT should be interpreted with caution, as people allocated to mirtazapine had less-severe symptoms at baseline, and the withdrawal rate was 31%
Effect size not calculatedmirtazapine

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
29 people
Data from 1 RCT
Proportion of people withdrawing
with mirtazapine
with placebo
Absolute results not reported

RR 1.20
95% CI 0.29 to 2.82
Not significant

RCT
29 people
In review
Proportion of people withdrawing
with
with
Absolute results not reported

RCT
26 people
In review
Proportion of people with palpitations
0/17 (0%) with mirtazapine
3/9 (33%) with placebo

P = 0.03
Effect size not calculatedmirtazapine

RCT
26 people
In review
Proportion of people with increased appetite
6/17 (35%) with mirtazapine
1/9 (11%) with placebo

P value not reported

RCT
26 people
In review
Proportion of people with weight gain
3/17 (18%) with mirtazapine
1/9 (11%) with placebo

P value not reported

Further information on studies

None.

Comment

All antidepressants have been associated with increased risk of suicidal thinking and behaviour in young adults ages 18 to 24 years (see harms of prescription antidepressant drugs in review on depression in adults [drug and other physical treatments]).

Clinical guide:

There is limited evidence for the use of mirtazapine.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Nefazodone to treat PTSD

Summary

We don't know whether nefazodone is beneficial in people with PTSD.

We found limited evidence that sertraline and nefazodone may be equally effective at improving symptoms of PTSD, but we don't know how other antidepressants compare with each other in the treatment of PTSD.

We found no clinically important results from RCTs about the effects of nefazodone compared with placebo in improving symptoms of PTSD.

Benefits and harms

Nefazodone versus placebo:

We found no systematic review or RCTs

Nefazodone versus sertraline:

See option on SSRIs versus other antidepressants.

Further information on studies

None.

Comment

All antidepressants have been associated with increased risk of suicidal thinking and behaviour in young adults ages 18 to 24 years (see harms of prescription antidepressant drugs in review on depression in adults [drug and other physical treatments]).

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Olanzapine to treat PTSD

Summary

We don't know whether olanzapine is beneficial in people with PTSD.

Benefits and harms

Olanzapine versus placebo:

We found one systematic review (search date 2004, 2 RCTs). The first RCT (15 people with PTSD, of whom 4 withdrew) did not meet Clinical Evidence reporting criteria because of small sample size and loss to follow-up.

Symptom severity

Olanzapine compared with placebo We don't know whether olanzapine is more effective than placebo at reducing the severity of symptoms of PTSD in people taking SSRIs but not responding in the first 12 weeks (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

Systematic review
19 people receiving SSRIs but not responding within the first 12 weeks of SSRI treatment
Data from 1 RCT
Clinician-rated PTSD symptoms 10 weeks
with olanzapine
with placebo
Absolute results not reported

SMD –0.92
95% CI –1.88 to +0.04
Not significant

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

Clinical guide:

There is insufficient evidence for the use of olanzapine at present.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Paroxetine (selective serotonin reuptake inhibitor) to treat PTSD:

Summary

Paroxetine may improve symptoms in people with PTSD.

SSRIs cause adverse effects including nausea and headache, and have been associated with an increased risk of self-harm in adults.

Benefits and harms

Paroxetine versus placebo:

We found one systematic review (search date 2004, 4 RCTs, 1086 people).

Symptom severity

Paroxetine compared with placebo Paroxetine is more effective at reducing severity of symptoms of PTSD (high-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

Systematic review
1070 people
3 RCTs in this analysis
Severity of clinician-rated PTSD symptoms
with paroxetine
with placebo
Absolute results not reported

SMD –0.42
95% CI –0.55 to –0.30
Effect size not calculatedparoxetine

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
1196 people
3 RCTs in this analysis
Proportion of people withdrawing
188/692 (27%) with paroxetine
129/504 (26%) with placebo

RR 0.95
95% CI 0.79 to 1.15
Not significant

RCT
307 people
In review
Proportion of people with nausea
19% with paroxetine
8% with placebo
Absolute numbers not reported

RCT
307 people
In review
Proportion of people with somnolence
17% with paroxetine
4% with placebo
Absolute numbers not reported

RCT
307 people
In review
Proportion of people with dry mouth
14% with paroxetine
5% with placebo
Absolute numbers not reported

RCT
307 people
In review
Proportion of people with asthenia
13% with paroxetine
5% with placebo
Absolute numbers not reported

RCT
307 people
In review
Proportion of people with abnormal ejaculation
12% with paroxetine
4% with placebo
Absolute numbers not reported

Further information on studies

None.

Comment

All antidepressants have been associated with increased risk of suicidal thinking and behaviour in young adults aged 18 to 24 years (see harms of prescription antidepressant drugs in review on depression in adults [drug and other physical treatments]). There is limited robust evidence available to examine the link between SSRIs and increased risk of self-harm or suicide in adults and, in light of this, practitioners should be guided by the recommendations and warnings issued by their national drug regulatory authorities with respect to the prescribing of antidepressants, particularly in children and adolescents (see review on depression in children and adolescents).

Clinical guide:

There is limited evidence for the use of paroxetine.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Phenelzine to treat PTSD

Summary

We don't know whether phenelzine is beneficial in people with PTSD.

Monoamine oxidase inhibitors (MAOIs) may require dietary restriction and can precipitate a hypertensive crisis.

Benefits and harms

Phenelzine versus placebo:

We found one systematic review (search date 2004, 1 RCT, 37 people).

Symptom severity

Phenelzine compared with placebo Phenelzine seems more effective at reducing the severity of symptoms of PTSD at 8 weeks (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

Systematic review
37 people
Data from 1 RCT
Self-reported PTSD symptoms 8 weeks
with phenelzine
with placebo
Absolute results not reported

SMD –1.06
95% CI –1.75 to –0.36
Effect size not calculatedphenelzine

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
37 people
Data from 1 RCT
Withdrawal rate
with phenelzine
with placebo
Absolute results not reported

RR 0.32
95% CI 0.12 to 0.80
Moderate effect sizephenelzine

Further information on studies

None.

Comment

Clinical guide:

There is limited evidence for the use of phenelzine at present.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Psychodynamic psychotherapy to treat PTSD

Summary

We don't know whether psychodynamic psychotherapy is beneficial in people with PTSD.

Benefits and harms

Psychodynamic psychotherapy versus waiting list control:

We found one systematic review (search date 2004), which identified one RCT.

Symptom severity

Psychodynamic psychotherapy compared with waiting list control Psychodynamic psychotherapy may be more effective at reducing PTSD symptom severity (intrusion/avoidance) at 4 months (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Intrusion/avoidance symptoms

RCT
4-armed trial
112 people
In review
Improvement in intrusion/avoidance score from baseline 4 months
19.3 with psychodynamic psychotherapy
4.6 with waiting list control

P <0.05
Effect size not calculatedpsychodynamic psychotherapy

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

Clinical guide:

There is no good evidence from RCTs to support the use of psychodynamic psychotherapy at present.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Risperidone to treat PTSD

Summary

We don't know whether risperidone is beneficial in people with PTSD.

Benefits and harms

Risperidone versus placebo:

We found one systematic review (search date 2004, 1 RCT, 37 people) and two subsequent RCTs.

Symptom severity

Risperidone compared with placebo We don't know whether adjunctive risperidone is more effective at reducing the severity of symptoms of PTSD at 5 weeks to 4 months in people also taking other medication (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

Systematic review
37 people
Data from 1 RCT
Reduction in severity of clinician-rated PTSD symptoms 5 weeks
with adjunctive risperidone
with placebo
Absolute results not reported

SMD +0.10
95% CI –0.55 to +0.74
The results from this RCT should be interpreted with caution because of the variability in the other medications being taken
Not significant

RCT
65 men with PTSD after military service Mean change in Clinician Administered PTSD Scale score
–14.3 with adjunctive risperidone 3 mg daily for 4 months
–4.6 with placebo

P <0.05
Effect size not calculatedrisperidone

RCT
21 women with PTSD Mean change in Clinician Administered PTSD Scale score
–29.6 with risperidone 0.5–8 mg (mean 1.41 mg) daily for 8 weeks
–18.6 with placebo

P = 0.015
Effect size not calculatedrisperidone

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
40 people
Data from 1 RCT
Proportion of people withdrawing from RCT
1/20 (5%) with adjunctive risperidone
2/20 (10%) with placebo

RR 0.50
95% CI 0.05 to 5.08
Not significant

RCT
65 men with PTSD after military service Proportion of people withdrawing from RCT
11/22 (50%) with adjunctive risperidone 3 mg daily for 4 months
6/25 (24%) with placebo

P >0.18
Not significant

No data from the following reference on this outcome.

Further information on studies

None.

Comment

Clinical guide:

There is some limited evidence for the use of risperidone.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Sertraline (selective serotonin reuptake inhibitor) to treat PTSD

Summary

We found insufficient good evidence to assess the effects of sertraline.

We found limited evidence that sertraline and nefazodone may be equally effective at improving symptoms of PTSD, but we don't know how other antidepressants compare with each other in the treatment of PTSD.

SSRIs cause adverse effects including nausea and headache, and have been associated with an increased risk of self-harm in adults.

Benefits and harms

Sertraline versus placebo:

We found one systematic review (search date 2004, 8 RCTs, 1505 people) and one subsequent RCT.

Symptom severity

Sertraline compared with placebo We don't know whether sertraline is more effective than placebo at reducing symptom severity of PTSD at 12 weeks (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

Systematic review
1123 people
6 RCTs in this analysis
Severity of clinician-rated symptoms of PTSD
with sertraline
with placebo
Absolute results not reported

SMD –0.26
95% CI –0.51 to 0
Result is of borderline significance
Not significant

RCT
169 people with combat-related PTSD Mean change in Clinician Administered PTSD Scale 12 weeks
–13.1 with sertraline (25–200 mg/day, flexible dose)
–15.4 with placebo

Reported as not significant
P value not reported
Not significant

Incidence of PTSD

Sertraline compared with placebo Sertraline is more effective at reducing the proportion of people with PTSD (high-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

Systematic review
747 people
2 RCTs in this analysis
Proportion of people fulfilling diagnostic criteria for PTSD
281/367 (77%) with sertraline
318/380 (84%) with placebo

RR 0.91
95% CI 0.85 to 0.98
Small effect sizesertraline

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects (any)

Systematic review
1148 people
6 RCTs in this analysis
Proportion of people withdrawing from RCT
151/571 (26%) with sertraline
138/577 (24%) with placebo

RR 1.10
95% CI 0.90 to 1.33
Not significant

RCT
208 people
In review
Proportion of people with insomnia
35% with sertraline
22% with placebo
Absolute numbers not reported

P = 0.04
Effect size not calculatedplacebo

RCT
208 people
In review
Proportion of people with diarrhoea
28% with sertraline
11% with placebo
Absolute numbers not reported

P = 0.003
Effect size not calculatedplacebo

RCT
208 people
In review
Proportion of people with nausea
23% with sertraline
11% with placebo
Absolute numbers not reported

P = 0.03
Effect size not calculatedplacebo

RCT
208 people
In review
Proportion of people with decreased appetite
12% with sertraline
1% with placebo
Absolute numbers not reported

P = 0.001
Effect size not calculatedplacebo

RCT
169 people with combat-related PTSD Proportion of people with fatigue 12 weeks
9/86 (11%) with sertraline (25–200 mg/day, flexible dose)
1/83 (1%) with placebo

P = 0.018
Effect size not calculatedplacebo

RCT
169 people with combat-related PTSD Proportion of people discontinuing treatment 12 weeks
26/86 (30%) with sertraline (25–200 mg/day, flexible dose)
14/83 (17%) with placebo

P = 0.041
Effect size not calculatedplacebo

RCT
169 people with combat-related PTSD Proportion of people with diarrhoea 12 weeks
27/86 (31%) with sertraline (25–200 mg/day, flexible dose)
15/83 (18%) with placebo

Reported as not significant
P value not reported
Not significant

RCT
169 people with combat-related PTSD Proportion of people with headache 12 weeks
23/86 (27%) with sertraline (25–200 mg/day, flexible dose)
20/83 (24%) with placebo

Reported as not significant
P value not reported
Not significant

RCT
169 people with combat-related PTSD Proportion of people with insomnia 12 weeks
12/86 (14%) with sertraline (25–200 mg/day, flexible dose)
8/83 (10%) with placebo

Reported as not significant
P value not reported
Not significant

Sertraline versus nefazodone:

See option on SSRIs versus other antidepressants.

Further information on studies

None.

Comment

All antidepressants have been associated with increased risk of suicidal thinking and behaviour in young adults aged 18 to 24 years (see harms of prescription antidepressant drugs in review on depression in adults [drug and other physical treatments]). There is limited robust evidence available to examine the link between SSRIs and increased risk of self-harm or suicide in adults and, in light of this, practitioners should be guided by the recommendations and warnings issued by their national drug regulatory authorities with respect to the prescribing of antidepressants, particularly in children and adolescents (see review on depression in children and adolescents).

Clinical guide:

There is some limited evidence for the use of paroxetine, but less for other SSRIs.

Substantive changes

Sertraline to treat PTSD One RCT added found no significant difference between sertraline and placebo in PTSD symptoms at 12 weeks. Categorisation unchanged (Unknown effectiveness).

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

SSRIs versus other antidepressants to treat PTSD

Summary

We found limited evidence that sertraline and nefazodone may be equally effective at improving symptoms of PTSD, but we don't know how other antidepressants compare with each other in the treatment of PTSD.

SSRIs cause adverse effects including nausea and headache, and have been associated with an increased risk of self-harm in adults.

Benefits and harms

Sertraline versus nefazodone:

We found two RCTs comparing sertraline versus nefazodone.

Symptom severity

Sertraline compared with nefazodone We don't know whether sertraline is more effective than nefazodone at reducing the severity of symptoms of PTSD at 5 months (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

RCT
60 people with PTSD Mean total 8-item PTSD scale (TOP-8) score 5 months
5.23 with sertraline 50–100 mg daily
4.35 with nefazodone 200–400 mg daily

P = 0.36
The results of this RCT should be interpreted with caution because, despite randomisation, people taking sertraline had significantly higher baseline TOP-8 scores than people taking nefazodone
Not significant

RCT
37 people with PTSD Change in Clinician Administered PTSD Scale (change from baseline)
from 73.8 to 29.1 with sertraline (mean dose 153 mg/day)
from 68.9 to 28.8 with nefazodone (mean dose 463 mg/day)

Reported as not significant
P value not reported
Not significant

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

All antidepressants have been associated with increased risk of suicidal thinking and behaviour in young adults aged 18 to 24 years (see harms of prescription antidepressant drugs in review on depression in adults [drug and other physical treatments]). There is limited robust evidence available to examine the link between SSRIs and increased risk of self-harm or suicide in adults and, in light of this, practitioners should be guided by the recommendations and warnings issued by their national drug regulatory authorities with respect to the prescribing of antidepressants, particularly in children and adolescents (see review on depression in children and adolescents).

Clinical guide:

There is some limited evidence for the use of paroxetine, but less for other SSRIs.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Supportive psychotherapy to treat PTSD

Summary

We don't know whether supportive psychotherapy is beneficial in people with PTSD.

Benefits and harms

Supportive psychotherapy versus waiting list control:

We found one systematic review (search date 2004), which identified one RCT.

Incidence of PTSD

Supportive psychotherapy compared with waiting list control Supportive psychotherapy seems no more effective than waiting list control at reducing the rate of PTSD (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

Systematic review
51 people
Data from 1 RCT
Proportion of people with PTSD
21/36 (58%) with supportive psychotherapy
18/25 (72%) with waiting list control

RR 0.81
95% CI 0.56 to 1.17
Not significant

Symptom severity

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Supportive psychotherapy versus CBT:

We found one systematic review (search date 2004).

Incidence of PTSD

Supportive psychotherapy compared with trauma-focused CBT Supportive psychotherapy and trauma-focused CBT seem equally effective at reducing the rate of PTSD (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Proportion of people with PTSD

Systematic review
73 people
Data from 1 RCT
Proportion of people with PTSD
16/37 (43%) with trauma-focused CBT
21/36 (58%) with supportive psychotherapy

RR 0.74
95% CI 0.47 to 1.18
Not significant

Symptom severity

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

Clinical guide:

There is no evidence from RCTs to support the use of supportive psychotherapy at present.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Tricyclic antidepressants to treat PTSD

Summary

We found insufficient good evidence to assess the effects of tricyclic antidepressants.

Tricyclic antidepressants are associated with anticholinergic adverse effects.

Benefits and harms

Tricyclic antidepressants versus placebo:

We found one systematic review (search date 2004, 2 RCTs, 81 people) comparing tricyclic antidepressants versus placebo.

Symptom severity

Amitriptyline compared with placebo Amitriptyline may be more effective at reducing the severity of self-reported symptoms of PTSD at 8 weeks, but we don't know whether imipramine is more effective than placebo at reducing self-reported symptom severity at 8 weeks (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

Systematic review
33 people
Data from 1 RCT
Severity of self-reported PTSD symptoms 8 weeks
with amitriptyline
with placebo
Absolute results not reported

SMD –0.90
95% CI –1.62 to –0.18
Effect size not calculatedamitriptyline

Systematic review
41 people
Data from 1 RCT
Severity of self-reported PTSD symptoms 8 weeks
with imipramine
with placebo
Absolute results not reported

SMD –0.24
95% CI –0.86 to +0.38
Not significant

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
46 people
Data from 1 RCT
Proportion of people withdrawing from an RCT 8 weeks
8/25 (32%) with amitriptyline
5/21 (25%) with placebo

RR 1.34
95% CI 0.52 to 3.49
Known adverse effects of tricyclic antidepressants include anticholinergic effects (see harms of prescription antidepressant drugs in review on depression in adults [drug and other physical treatments])
Not significant

Systematic review
41 people
Data from 1 RCT
Proportion of people withdrawing from an RCT 8 weeks
12/23 (52%) with imipramine
12/18 (67%) with placebo

RR 0.78
95% CI 0.47 to 1.3
Known adverse effects of tricyclic antidepressants include anticholinergic effects (see harms of prescription antidepressant drugs in review on depression in adults [drug and other physical treatments])
Not significant

Further information on studies

None.

Comment

Clinical guide:

There is limited evidence from one small RCT for the use of amitriptyline.

Substantive changes

No new evidence

BMJ Clin Evid. 2010; 2010: 1005.
Published online 2010 February 3.

Venlafaxine to treat PTSD

Summary

Venlafaxine does not seem effective at improving symptoms.

SSRIs cause adverse effects including nausea and headache, and have been associated with an increased risk of self-harm in adults.

Benefits and harms

Venlafaxine versus placebo:

We found one systematic review (search date 2004, 1 RCT, 358 people).

Symptom severity

Venlafaxine compared with placebo Venlafaxine seems no more effective than placebo at reducing the severity of symptoms of PTSD at 12 weeks (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
PTSD symptoms

Systematic review
358 people
Data from 1 RCT
Severity of clinician-rated PTSD symptoms 12 weeks
with venlafaxine
with placebo
Absolute results not reported

SMD –0.14
95% CI –0.35 to +0.06
Not significant

Incidence of PTSD

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
358 people
Data from 1 RCT
Proportion of people withdrawing from RCT 12 weeks
54/179 (32%) with venlafaxine
65/179 (36%) with placebo

RR 0.83
95% CI 0.62 to 1.12
Not significant

Further information on studies

None.

Comment

All antidepressants have been associated with increased risk of suicidal thinking and behaviour in young adults ages 18 to 24 years (see harms of prescription antidepressant drugs in review on depression in adults [drug and other physical treatments]).

Clinical guide:

There is some limited evidence for the use of paroxetine, but less for other SSRIs.

Substantive changes

No new evidence


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