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Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults.
Cochrane Database Syst Rev. 2018 Dec 14; 12:CD011710.CD

Abstract

BACKGROUND

Therapist-delivered trauma-focused psychological therapies are an effective treatment for post-traumatic stress disorder (PTSD). These have become the accepted first-line treatments for the disorder. Despite the established evidence-base for these therapies, they are not always widely available or accessible. Many barriers limit treatment uptake, such as the limited number of qualified therapists to deliver the interventions, cost, and compliance issues, such as time off work, childcare, and transportation, associated with the need to attend weekly appointments. Delivering cognitive behavioural therapy (CBT) on the Internet is an effective and acceptable alternative to therapist-delivered treatments for anxiety and depression. However, fewer Internet-based therapies have been developed and evaluated for PTSD, and uncertainty surrounds the efficacy of Internet-based cognitive and behavioural therapy (I-C/BT) for PTSD.

OBJECTIVES

To assess the effects of I-C/BT for PTSD in adults.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group's Specialised Register (CCMDCTR) to June 2016 and identified four studies meeting the inclusion criteria. The CCMDCTR includes relevant randomised controlled trials (RCT) from MEDLINE, Embase, and PsycINFO. We also searched online clinical trial registries and reference lists of included studies, and contacted researchers in the field to identify additional and ongoing studies. We ran an update search on 1 March 2018, and identified four additional completed studies, which we added to the analyses along with two that were previously awaiting classification.

SELECTION CRITERIA

We searched for RCTs of I-C/BT compared to face-to-face or Internet-based psychological treatment, psychoeducation, wait list or care as usual. We included studies of adults (aged over 16 years or over), in which at least 70% of the participants met the diagnostic criteria for PTSD, according to the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD).

DATA COLLECTION AND ANALYSIS

We entered data into Review Manager 5 software. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data with a fixed-effect meta-analysis, except where heterogeneity was present, in which case we used a random-effects model. Two review authors independently assessed the included studies for risk of bias; any conflicts were discussed with a third author, with the aim of reaching a unanimous decision.

MAIN RESULTS

We included 10 studies with 720 participants in the review. Eight of the studies compared I-C/BT delivered with therapist guidance to a wait list control. Two studies compared guided I-C/BT with I-non-C/BT. There was considerable heterogeneity among the included studies.Very low-quality evidence showed that, compared with wait list, I-C/BT may be associated with a clinically important reduction in PTSD post-treatment (SMD -0.60, 95% CI -0.97 to -0.24; studies = 8, participants = 560). However, there was no evidence of a difference in PTSD symptoms when follow-up was less than six months (SMD -0.43, 95% CI -1.41 to 0.56; studies = 3, participants = 146). There may be little or no difference in dropout rates between the I-C/BT and wait list groups (RR 1.39, 95% CI 1.03 to 1.88; studies = 8, participants = 585; low-quality evidence). I-C/BT was no more effective than wait list at reducing the risk of a diagnosis of PTSD after treatment (RR 0.53, 95% CI 0.28 to 1.00; studies = 1, participants = 62; very low-quality evidence). I-C/BT may be associated with a clinically important reduction in symptoms of depression both post-treatment (SMD -0.61, 95% CI -1.17 to -0.05; studies = 5, participants = 425; very low-quality evidence). Very low-quality evidence also suggested that I-C/BT may be associated with a clinically important reduction in symptoms of anxiety post-treatment (SMD -0.67, 95% CI -0.98 to -0.36; studies = 4, participants = 305), and at follow-up less than six months (MD -12.59, 95% CI -20.74 to -4.44; studies = 1, participants = 42; very low-quality evidence). The effects of I-C/BT on quality of life were uncertain (SMD 0.60, 95% CI 0.08 to 1.12; studies = 2, participants = 221; very low-quality evidence).Two studies found no difference in PTSD symptoms between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD -0.08, 95% CI -0.52 to 0.35; studies = 2, participants = 82; very low-quality evidence), or when follow-up was less than six months (SMD 0.08, 95% CI -0.41 to 0.57; studies = 2, participants = 65; very low-quality evidence). However, those who received I-C/BT reported their PTSD symptoms were better at six- to 12-month follow-up (MD -8.83, 95% CI -17.32 to -0.34; studies = 1, participants = 18; very low-quality evidence). Two studies found no difference in depressive symptoms between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD -0.12, 95% CI -0.78 to 0.54; studies = 2, participants = 84; very low-quality evidence) or when follow-up was less than six months (SMD 0.20, 95% CI -0.31 to 0.71; studies = 2, participants = 61; very low-quality evidence). However, those who received I-C/BT reported their depressive symptoms were better at six- to 12-month follow-up (MD -8.34, 95% CI -15.83 to -0.85; studies = 1, participants = 18; very low-quality evidence). Two studies found no difference in symptoms of anxiety between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD 0.08, 95% CI -0.78 to 0.95; studies = 2, participants = 74; very low-quality evidence) or when follow-up was less than six months (SMD -0.16, 95% CI -0.67 to 0.35; studies = 2, participants = 60; very low-quality evidence). However, those who received I-C/BT reported their symptoms of anxiety were better at six- to 12-month follow-up (MD -8.05, 95% CI -15.20 to -0.90; studies = 1, participants = 18; very low-quality evidence).None of the included studies reported on cost-effectiveness or adverse events.

AUTHORS' CONCLUSIONS

While the review found some beneficial effects of I-C/BT for PTSD, the quality of the evidence was very low due to the small number of included trials. Further work is required to: establish non-inferiority to current first-line interventions, explore mechanisms of change, establish optimal levels of guidance, explore cost-effectiveness, measure adverse events, and determine predictors of efficacy and dropout.

Authors+Show Affiliations

Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Hadyn Ellis Building, Maindy Road, Cardiff, UK, CF24 4HQ.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Systematic Review

Language

eng

PubMed ID

30550643

Citation

Lewis, Catrin, et al. "Internet-based Cognitive and Behavioural Therapies for Post-traumatic Stress Disorder (PTSD) in Adults." The Cochrane Database of Systematic Reviews, vol. 12, 2018, p. CD011710.
Lewis C, Roberts NP, Bethell A, et al. Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults. Cochrane Database Syst Rev. 2018;12:CD011710.
Lewis, C., Roberts, N. P., Bethell, A., Robertson, L., & Bisson, J. I. (2018). Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults. The Cochrane Database of Systematic Reviews, 12, CD011710. https://doi.org/10.1002/14651858.CD011710.pub2
Lewis C, et al. Internet-based Cognitive and Behavioural Therapies for Post-traumatic Stress Disorder (PTSD) in Adults. Cochrane Database Syst Rev. 2018 Dec 14;12:CD011710. PubMed PMID: 30550643.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults. AU - Lewis,Catrin, AU - Roberts,Neil P, AU - Bethell,Andrew, AU - Robertson,Lindsay, AU - Bisson,Jonathan I, Y1 - 2018/12/14/ PY - 2018/12/15/pubmed PY - 2019/3/7/medline PY - 2018/12/15/entrez SP - CD011710 EP - CD011710 JF - The Cochrane database of systematic reviews JO - Cochrane Database Syst Rev VL - 12 N2 - BACKGROUND: Therapist-delivered trauma-focused psychological therapies are an effective treatment for post-traumatic stress disorder (PTSD). These have become the accepted first-line treatments for the disorder. Despite the established evidence-base for these therapies, they are not always widely available or accessible. Many barriers limit treatment uptake, such as the limited number of qualified therapists to deliver the interventions, cost, and compliance issues, such as time off work, childcare, and transportation, associated with the need to attend weekly appointments. Delivering cognitive behavioural therapy (CBT) on the Internet is an effective and acceptable alternative to therapist-delivered treatments for anxiety and depression. However, fewer Internet-based therapies have been developed and evaluated for PTSD, and uncertainty surrounds the efficacy of Internet-based cognitive and behavioural therapy (I-C/BT) for PTSD. OBJECTIVES: To assess the effects of I-C/BT for PTSD in adults. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Group's Specialised Register (CCMDCTR) to June 2016 and identified four studies meeting the inclusion criteria. The CCMDCTR includes relevant randomised controlled trials (RCT) from MEDLINE, Embase, and PsycINFO. We also searched online clinical trial registries and reference lists of included studies, and contacted researchers in the field to identify additional and ongoing studies. We ran an update search on 1 March 2018, and identified four additional completed studies, which we added to the analyses along with two that were previously awaiting classification. SELECTION CRITERIA: We searched for RCTs of I-C/BT compared to face-to-face or Internet-based psychological treatment, psychoeducation, wait list or care as usual. We included studies of adults (aged over 16 years or over), in which at least 70% of the participants met the diagnostic criteria for PTSD, according to the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD). DATA COLLECTION AND ANALYSIS: We entered data into Review Manager 5 software. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data with a fixed-effect meta-analysis, except where heterogeneity was present, in which case we used a random-effects model. Two review authors independently assessed the included studies for risk of bias; any conflicts were discussed with a third author, with the aim of reaching a unanimous decision. MAIN RESULTS: We included 10 studies with 720 participants in the review. Eight of the studies compared I-C/BT delivered with therapist guidance to a wait list control. Two studies compared guided I-C/BT with I-non-C/BT. There was considerable heterogeneity among the included studies.Very low-quality evidence showed that, compared with wait list, I-C/BT may be associated with a clinically important reduction in PTSD post-treatment (SMD -0.60, 95% CI -0.97 to -0.24; studies = 8, participants = 560). However, there was no evidence of a difference in PTSD symptoms when follow-up was less than six months (SMD -0.43, 95% CI -1.41 to 0.56; studies = 3, participants = 146). There may be little or no difference in dropout rates between the I-C/BT and wait list groups (RR 1.39, 95% CI 1.03 to 1.88; studies = 8, participants = 585; low-quality evidence). I-C/BT was no more effective than wait list at reducing the risk of a diagnosis of PTSD after treatment (RR 0.53, 95% CI 0.28 to 1.00; studies = 1, participants = 62; very low-quality evidence). I-C/BT may be associated with a clinically important reduction in symptoms of depression both post-treatment (SMD -0.61, 95% CI -1.17 to -0.05; studies = 5, participants = 425; very low-quality evidence). Very low-quality evidence also suggested that I-C/BT may be associated with a clinically important reduction in symptoms of anxiety post-treatment (SMD -0.67, 95% CI -0.98 to -0.36; studies = 4, participants = 305), and at follow-up less than six months (MD -12.59, 95% CI -20.74 to -4.44; studies = 1, participants = 42; very low-quality evidence). The effects of I-C/BT on quality of life were uncertain (SMD 0.60, 95% CI 0.08 to 1.12; studies = 2, participants = 221; very low-quality evidence).Two studies found no difference in PTSD symptoms between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD -0.08, 95% CI -0.52 to 0.35; studies = 2, participants = 82; very low-quality evidence), or when follow-up was less than six months (SMD 0.08, 95% CI -0.41 to 0.57; studies = 2, participants = 65; very low-quality evidence). However, those who received I-C/BT reported their PTSD symptoms were better at six- to 12-month follow-up (MD -8.83, 95% CI -17.32 to -0.34; studies = 1, participants = 18; very low-quality evidence). Two studies found no difference in depressive symptoms between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD -0.12, 95% CI -0.78 to 0.54; studies = 2, participants = 84; very low-quality evidence) or when follow-up was less than six months (SMD 0.20, 95% CI -0.31 to 0.71; studies = 2, participants = 61; very low-quality evidence). However, those who received I-C/BT reported their depressive symptoms were better at six- to 12-month follow-up (MD -8.34, 95% CI -15.83 to -0.85; studies = 1, participants = 18; very low-quality evidence). Two studies found no difference in symptoms of anxiety between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD 0.08, 95% CI -0.78 to 0.95; studies = 2, participants = 74; very low-quality evidence) or when follow-up was less than six months (SMD -0.16, 95% CI -0.67 to 0.35; studies = 2, participants = 60; very low-quality evidence). However, those who received I-C/BT reported their symptoms of anxiety were better at six- to 12-month follow-up (MD -8.05, 95% CI -15.20 to -0.90; studies = 1, participants = 18; very low-quality evidence).None of the included studies reported on cost-effectiveness or adverse events. AUTHORS' CONCLUSIONS: While the review found some beneficial effects of I-C/BT for PTSD, the quality of the evidence was very low due to the small number of included trials. Further work is required to: establish non-inferiority to current first-line interventions, explore mechanisms of change, establish optimal levels of guidance, explore cost-effectiveness, measure adverse events, and determine predictors of efficacy and dropout. SN - 1469-493X UR - https://www.unboundmedicine.com/medline/citation/30550643/Internet_based_cognitive_and_behavioural_therapies_for_post_traumatic_stress_disorder__PTSD__in_adults_ L2 - https://doi.org/10.1002/14651858.CD011710.pub2 DB - PRIME DP - Unbound Medicine ER -