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. 2018 Dec 14;12(12):CD011710.
doi: 10.1002/14651858.CD011710.pub2.

Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults

Catrin Lewis  1 , Neil P Roberts, Andrew Bethell, Lindsay Robertson, Jonathan I Bisson
Affiliations

Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults

Catrin Lewis et al. Cochrane Database Syst Rev. .

Update in

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.

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Conflict of interest statement

CL: involved in the development and evaluation of an online, guided self‐help programme (Spring: a step‐by‐step treatment programme for PTSD) in conjunction with the software development company Healthcare Learning Smile‐on.

NR: involved in the development and evaluation of an online, guided self‐help programme (Spring: a step‐by‐step treatment programme for PTSD) in conjunction with the software development company Healthcare Learning Smile‐on.

AB: none.

LR: none.

JB: involved in the development and evaluation of an online, guided self‐help programme (Spring: a step‐by‐step treatment programme for PTSD) in conjunction with the software development company Healthcare Learning Smile‐on.

Clarification statement added from the Co‐ordinating Editor on 21 May 2020: This review was found by the Cochrane Funding Arbiters, post‐publication, to be noncompliant with theCochrane conflict of interest policy, which includes the relevant parts of theCochrane Commercial Sponsorship Policy. It will be updated within 12 months. The update will have a majority of authors and lead author free of conflicts.

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias domain presented as percentages across all included studies.
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias domain for each included study.
1.1
1.1. Analysis
Comparison 1: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus wait list (WL), Outcome 1: Severity of PTSD symptoms (post‐treatment)
1.2
1.2. Analysis
Comparison 1: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus wait list (WL), Outcome 2: Severity of PTSD symptoms (follow‐up < 6 months)
1.3
1.3. Analysis
Comparison 1: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus wait list (WL), Outcome 3: Dropouts
1.4
1.4. Analysis
Comparison 1: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus wait list (WL), Outcome 4: Diagnosis of PTSD after treatment
1.5
1.5. Analysis
Comparison 1: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus wait list (WL), Outcome 5: Severity of depression (post‐treatment)
1.6
1.6. Analysis
Comparison 1: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus wait list (WL), Outcome 6: Severity of depression (follow‐up < 6 months)
1.7
1.7. Analysis
Comparison 1: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus wait list (WL), Outcome 7: Severity of anxiety symptoms (post‐treatment)
1.8
1.8. Analysis
Comparison 1: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus wait list (WL), Outcome 8: Severity of anxiety symptoms (follow‐up < 6 months)
1.9
1.9. Analysis
Comparison 1: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus wait list (WL), Outcome 9: Quality of Life (post‐treatment)
2.1
2.1. Analysis
Comparison 2: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus I‐non‐C/BT, Outcome 1: Severity of PTSD symptoms (post‐treatment)
2.2
2.2. Analysis
Comparison 2: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus I‐non‐C/BT, Outcome 2: Severity of PTSD symptoms (follow‐up < 6 months)
2.3
2.3. Analysis
Comparison 2: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus I‐non‐C/BT, Outcome 3: Severity of PTSD symptoms (follow‐up 6–12 months)
2.4
2.4. Analysis
Comparison 2: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus I‐non‐C/BT, Outcome 4: Dropouts
2.5
2.5. Analysis
Comparison 2: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus I‐non‐C/BT, Outcome 5: Severity of depressive symptoms (post‐treatment)
2.6
2.6. Analysis
Comparison 2: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus I‐non‐C/BT, Outcome 6: Severity of depressive symptoms (follow‐up < 6 months)
2.7
2.7. Analysis
Comparison 2: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus I‐non‐C/BT, Outcome 7: Severity of depressive symptoms (follow‐up 6–12 months)
2.8
2.8. Analysis
Comparison 2: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus I‐non‐C/BT, Outcome 8: Severity of anxiety symptoms (post‐treatment)
2.9
2.9. Analysis
Comparison 2: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus I‐non‐C/BT, Outcome 9: Severity of anxiety symptoms (follow‐up < 6 months)
2.10
2.10. Analysis
Comparison 2: Internet‐based cognitive and behavioural therapy (I‐C/BT) versus I‐non‐C/BT, Outcome 10: Severity of anxiety symptoms (follow‐up 6–12 months)
See this image and copyright information in PMC

References

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NCT01508377 {published data only}
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References to ongoing studies

ACTRN12611000989943 {published data only}
    1. ACTRN12611000989943. A comparison of Internet-based cognitive behavioural therapy for posttraumatic stress disorder with and without exposure: a randomized controlled trial. www.anzctr.org.au/ACTRN12611000989943.aspx Date first received: 16 September 2011.
ACTRN12614001213639 {published data only}
    1. ACTRN12614001213639. Internet treatment for posttraumatic stress disorder (PTSD). www.anzctr.org.au/ACTRN12614001213639.aspx Date first received: 18 November 2014.
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ACTRN12616000956404 {published data only}
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DRKS00010245 {published data only}
    1. DRKS00010245. Evaluation of web-based cognitive and behavioural therapeutic components and its change mechanisms for Arab people with posttraumatic stress disorder. www.drks.de/DRKS00010245 Date first received: 30 March 2016.
ISRCTN13697710 {published data only}
    1. ISRCTN13697710. A study of trauma-focused online guided self help versus trauma-focused cognitive behavioural therapy for post-traumatic stress disorder. isrctn.com/ISRCTN13697710 Date first received: 21 December 2016.
ISRCTN16806208 {published data only}
    1. ISRCTN16806208. A randomised controlled trial of therapist-assisted online psychological therapies for post-traumatic stress disorder. isrctn.com/ISRCTN16806208 Date first received: 5 January 2018.
Lehavot 2017 {published data only}
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McLean 2017 {published data only}
    1. McLean CP, Rauch SA, Foa EB, Sripada RK, Tannahill HS, Mintz J, et al. Design of a randomized controlled trial examining the efficacy and biological mechanisms of web-prolonged exposure and present-centered therapy for PTSD among active-duty military personnel and veterans. Contemporary Clinical Trials 2017; 64:41-8. - PubMed
NCT02556645 {published data only}
    1. NCT02556645. A comparison of web-prolonged exposure (Web-PE) and present-centered therapy (PCT) for PTSD among active-duty military personnel. ClinicalTrials.gov/show/NCT02556645 Date first received: 22 September 2015.
NCT02611843 {published data only}
    1. NCT02611843. Peer supported web-based CBT for OEF/OIF veterans with PTSD and substance misuse. ClinicalTrials.gov/show/NCT02611843 Date first received: 23 November 2015.
NCT02929979 {published data only}
    1. NCT02929979. Cognitive remediation for alcohol use disorder and posttraumatic stress disorder. ClinicalTrials.gov/show/NCT02929979 Date first received: 11 October 2016.
NCT03208738 {published data only}
    1. NCT03208738. Pilot evaluation of the VetChange mobile app for veterans with PTSD who engage in problem drinking. ClinicalTrials.gov/show/NCT03208738 Date first registered: 5 July 2017.
NTR6912 {published data only}
    1. NTR6912. Addition of the SUPPORT Coach in PTSD treatment. www.trialregister.nl/trialreg/admin/rctview.asp?TC=6912 Date first received: 22 December 2017.

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References to other published versions of this review

Lewis 2015
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