What Are the Most Effective Psychotherapies for Post-Traumatic Stress Disorder?

What you need to know

• Meta-cognitive therapy and cognitive processing therapy showed the strongest effects in reducing PTSD symptoms compared to other psychotherapies.

• Written exposure therapy and narrative exposure therapy had the lowest dropout rates, suggesting they may be the most acceptable treatments for patients.

• Overall, most trauma-focused therapies were found to be effective, with some differences in efficacy and acceptability between specific approaches.

Background on PTSD and Psychotherapy Research

Post-traumatic stress disorder (PTSD) is a mental health condition that can develop after experiencing or witnessing a traumatic event. People with PTSD may have intrusive memories of the trauma, avoid reminders of it, experience negative changes in their thoughts and mood, and have heightened reactivity. PTSD affects about 8% of people at some point in their lives and can significantly impair daily functioning.

Many types of psychotherapy have been developed to treat PTSD, with most involving processing of the traumatic memories in some way. Previous research reviews have generally concluded that different trauma-focused therapies produce similar positive outcomes. However, these reviews have had some limitations in their methods. This new study aimed to provide a more comprehensive comparison of PTSD psychotherapies using an advanced statistical technique called network meta-analysis.

How the Study Was Conducted

The researchers conducted a systematic search of scientific databases to identify randomized controlled trials testing psychotherapies for adults with PTSD. They included 82 studies with a total of 5,838 participants.

The analysis compared 17 different psychotherapy approaches and 4 control conditions (like waitlist or supportive counseling). Some of the key therapies examined were:

• Cognitive behavioral therapy (CBT)
• Cognitive processing therapy (CPT)
• Prolonged exposure therapy (PE)
• Eye movement desensitization and reprocessing (EMDR)
• Narrative exposure therapy (NET)
• Metacognitive therapy (MCT)
• Written exposure therapy (WET)

The main outcomes analyzed were:

1. Efficacy - how much the therapy reduced PTSD symptoms
2. Acceptability - the proportion of patients who completed the full treatment (didn’t drop out)

The network meta-analysis allowed the researchers to compare therapies that had not been directly tested against each other in trials. This provided a more complete picture of how the different approaches compared.

Key Findings on Treatment Efficacy

In terms of reducing PTSD symptoms:

• Metacognitive therapy (MCT) and cognitive processing therapy (CPT) showed the strongest effects overall.

• MCT was significantly more effective than CBT, EMDR, NET, and control conditions.

• CPT was significantly better than CBT and control conditions.

• Prolonged exposure (PE) also performed well, being more effective than CBT and most control conditions.

• Most active therapies were superior to waitlist control.

The effect sizes suggest MCT and CPT produced approximately double the symptom improvement compared to therapies like EMDR and interpersonal therapy.

However, the researchers note there were only two small studies on MCT included, so more research is needed to confirm its effects. CPT has been studied more extensively.

Key Findings on Treatment Acceptability

Looking at treatment completion rates:

• Written exposure therapy (WET) and narrative exposure therapy (NET) had the lowest dropout rates.

• Patients were about half as likely to drop out of WET and NET compared to therapies like prolonged exposure, metacognitive therapy, and cognitive processing therapy.

• Prolonged exposure therapy combined with stress inoculation training had a significantly higher dropout rate than most other treatments.

This suggests brief writing-based therapies like WET and NET may be the most tolerable for patients. More intensive approaches like prolonged exposure appear to have higher dropout risks.

Conclusions and Implications

The analysis found meaningful differences in both efficacy and acceptability between PTSD psychotherapies, challenging the idea that all trauma-focused treatments produce equivalent outcomes. Key takeaways include:

• Metacognitive therapy and cognitive processing therapy appear to be the most effective for reducing PTSD symptoms, though more research on MCT is needed.

• Written exposure therapy and narrative exposure therapy may be good options to consider for their high acceptability/completion rates.

• Prolonged exposure therapy is effective but may have higher dropout risk for some patients.

• Most trauma-focused therapies outperformed non-trauma-focused approaches.

These findings can help inform treatment selection and clinical decision-making. Clinicians may want to consider using CPT as a first-line approach given its strong effects and research base. For patients at risk of dropping out, brief writing therapies could be good options to try.

The researchers emphasize that more head-to-head comparison studies between different trauma-focused therapies are still needed. This would provide stronger direct evidence on which approaches work best.

They also note some limitations of the analysis, including the overall low quality of many included studies and potential bias from small studies. More large, high-quality trials comparing trauma-focused therapies are recommended.

In conclusion, while most PTSD therapies appear beneficial, there are meaningful differences between approaches that clinicians and patients should consider when selecting treatment. Continued research can help further clarify the most effective ways to alleviate PTSD symptoms and improve outcomes for trauma survivors.