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. 2019 Aug 8;8(8):CD006869.
doi: 10.1002/14651858.CD006869.pub3.

Multiple session early psychological interventions for the prevention of post-traumatic stress disorder

Neil P Roberts  1 , Neil J Kitchiner, Justin Kenardy, Lindsay Robertson, Catrin Lewis, Jonathan I Bisson
Affiliations

Multiple session early psychological interventions for the prevention of post-traumatic stress disorder

Neil P Roberts et al. Cochrane Database Syst Rev. .

Abstract

Background: The prevention of long-term psychological distress following traumatic events is a major concern. Systematic reviews have suggested that individual psychological debriefing is not an effective intervention at preventing post-traumatic stress disorder (PTSD). Over the past 20 years, other forms of intervention have been developed with the aim of preventing PTSD.

Objectives: To examine the efficacy of psychological interventions aimed at preventing PTSD in individuals exposed to a traumatic event but not identified as experiencing any specific psychological difficulties, in comparison with control conditions (e.g. usual care, waiting list and no treatment) and other psychological interventions.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO and ProQuest's Published International Literature On Traumatic Stress (PILOTS) database to 3 March 2018. An earlier search of CENTRAL and the Ovid databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to May 2016). We handsearched reference lists of relevant guidelines, systematic reviews and included study reports. Identified studies were shared with key experts in the field.We conducted an update search (15 March 2019) and placed any new trials in the 'awaiting classification' section. These will be incorporated into the next version of this review, as appropriate.

Selection criteria: We searched for randomised controlled trials of any multiple session (two or more sessions) early psychological intervention or treatment designed to prevent symptoms of PTSD. We excluded single session individual/group psychological interventions. Comparator interventions included waiting list/usual care and active control condition. We included studies of adults who experienced a traumatic event which met the criterion A1 according to the Diagnostic and Statistical Manual (DSM-IV) for PTSD.

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 there was heterogeneity, in which case we used a random-effects model. Two review authors independently assessed the included studies for risk of bias and discussed any conflicts with a third review author.

Main results: This is an update of a previous review.We included 27 studies with 3963 participants. The meta-analysis included 21 studies of 2721 participants. Seventeen studies compared multiple session early psychological intervention versus treatment as usual and four studies compared a multiple session early psychological intervention with active control condition.Low-certainty evidence indicated that multiple session early psychological interventions may be more effective than usual care in reducing PTSD diagnosis at three to six months' follow-up (RR 0.62, 95% CI 0.41 to 0.93; I2 = 34%; studies = 5; participants = 758). However, there was no statistically significant difference post-treatment (RR 1.06, 95% CI 0.85 to 1.32; I2 = 0%; studies = 5; participants = 556; very low-certainty evidence) or at seven to 12 months (RR 0.94, 95% CI 0.20 to 4.49; studies = 1; participants = 132; very low-certainty evidence). Meta-analysis indicated that there was no statistical difference in dropouts compared with usual care (RR 1.34, 95% CI 0.91 to 1.95; I2 = 34%; studies = 11; participants = 1154; low-certainty evidence) .At the primary endpoint of three to six months, low-certainty evidence indicated no statistical difference between groups in reducing severity of PTSD (SMD -0.10, 95% CI -0.22 to 0.02; I2 = 34%; studies = 15; participants = 1921), depression (SMD -0.04, 95% CI -0.19 to 0.10; I2 = 6%; studies = 7; participants = 1009) or anxiety symptoms (SMD -0.05, 95% CI -0.19 to 0.10; I2 = 2%; studies = 6; participants = 945).No studies comparing an intervention and active control reported outcomes for PTSD diagnosis. Low-certainty evidence showed that interventions may be associated with a higher dropout rate than active control condition (RR 1.61, 95% CI 1.11 to 2.34; studies = 2; participants = 425). At three to six months, low-certainty evidence indicated no statistical difference between interventions in terms of severity of PTSD symptoms (SMD -0.02, 95% CI -0.31 to 0.26; I2 = 43%; studies = 4; participants = 465), depression (SMD 0.04, 95% CI -0.16 to 0.23; I2 = 0%; studies = 2; participants = 409), anxiety (SMD 0.00, 95% CI -0.19 to 0.19; I2 = 0%; studies = 2; participants = 414) or quality of life (MD -0.03, 95% CI -0.06 to 0.00; studies = 1; participants = 239).None of the included studies reported on adverse events or use of health-related resources.

Authors' conclusions: While the review found some beneficial effects of multiple session early psychological interventions in the prevention of PTSD, the certainty of the evidence was low due to the high risk of bias in the included trials. The clear practice implication of this is that, at present, multiple session interventions aimed at everyone exposed to traumatic events cannot be recommended. There are a number of ongoing studies, demonstrating that this is a fast moving field of research. Future updates of this review will integrate the results of these new studies.

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Conflict of interest statement

NPR: none.

NJK: none.

JK: none.

LR: none.

CL: none.

JIB: none.

Figures

1
1
PRISMA flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Funnel plot of comparison: 1 Any early psychological intervention versus waiting list/usual care, outcome: 1.5 Severity of PTSD symptoms: 3–6 months. TAU: treatment as usual.
5
5
Funnel plot of comparison: 1 Any early psychological intervention versus waiting list/usual care, outcome: 1.13 Dropouts for any reason. CBT: cognitive behavioural therapy; IPT: interpersonal therapy; TAU: treatment as usual.
1.1
1.1. Analysis
Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 1 PTSD diagnosis post‐treatment.
1.2
1.2. Analysis
Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 2 PTSD diagnosis 3–6 months.
1.3
1.3. Analysis
Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 3 PTSD diagnosis 7–12 months.
1.4
1.4. Analysis
Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 4 Dropouts from treatment.
1.5
1.5. Analysis
Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 5 Severity of PTSD symptoms post‐treatment.
1.6
1.6. Analysis
Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 6 Severity of PTSD symptoms: 3–6 months.
1.7
1.7. Analysis
Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 7 Severity of PTSD symptoms: 7–12 months.
1.8
1.8. Analysis
Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 8 Severity of depressive symptoms post‐treatment.
1.9
1.9. Analysis
Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 9 Severity of depressive symptoms at 3–6 months.
1.10
1.10. Analysis
Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 10 Severity of depressive symptoms at 7–12 months.
1.11
1.11. Analysis
Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 11 Severity of anxiety symptoms post‐treatment.
1.12
1.12. Analysis
Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 12 Severity of anxiety symptoms at 3–6 months.
1.13
1.13. Analysis
Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 13 Severity of anxiety symptoms at 7–12 months.
2.1
2.1. Analysis
Comparison 2 Any early psychological intervention versus active control condition, Outcome 1 Dropouts from treatment.
2.2
2.2. Analysis
Comparison 2 Any early psychological intervention versus active control condition, Outcome 2 Severity of PTSD symptoms post‐treatment.
2.3
2.3. Analysis
Comparison 2 Any early psychological intervention versus active control condition, Outcome 3 Severity of PTSD symptoms at 3–6 months.
2.4
2.4. Analysis
Comparison 2 Any early psychological intervention versus active control condition, Outcome 4 Severity of PTSD symptoms at 7–12 months.
2.5
2.5. Analysis
Comparison 2 Any early psychological intervention versus active control condition, Outcome 5 Severity of depression symptoms post‐treatment.
2.6
2.6. Analysis
Comparison 2 Any early psychological intervention versus active control condition, Outcome 6 Severity of depressive symptoms at 3–6 months.
2.7
2.7. Analysis
Comparison 2 Any early psychological intervention versus active control condition, Outcome 7 Severity of depressive symptoms at 7–12 months.
2.8
2.8. Analysis
Comparison 2 Any early psychological intervention versus active control condition, Outcome 8 Severity of anxiety symptoms post‐treatment.
2.9
2.9. Analysis
Comparison 2 Any early psychological intervention versus active control condition, Outcome 9 Severity of anxiety symptoms at 3–6 months.
2.10
2.10. Analysis
Comparison 2 Any early psychological intervention versus active control condition, Outcome 10 Severity of anxiety symptoms at 7–12 months.
2.11
2.11. Analysis
Comparison 2 Any early psychological intervention versus active control condition, Outcome 11 General functioning post‐treatment.
2.12
2.12. Analysis
Comparison 2 Any early psychological intervention versus active control condition, Outcome 12 General functioning at 3–6 months.
2.13
2.13. Analysis
Comparison 2 Any early psychological intervention versus active control condition, Outcome 13 General functioning at 7–12 months.
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    1. Shaw RJ, John N, Lilo EA, Jo B, Benitz W, Stevenson DK, Horwitz SM. Prevention of traumatic stress in mothers with preterm infants: A randomized controlled trial. Pediatrics 2013;132(4):e886‐94. - PMC - PubMed
    1. Shaw RJ, John N, Lilo EA, Jo B, Benitz W, Stevenson DK, et al. Prevention of traumatic stress in mothers of preterms: 6‐month outcomes. Pediatrics 2014;134(2):e481‐8. - PMC - PubMed
Sijbrandij 2007 {published and unpublished data}
    1. Sijbrandij M, Olff M, Reitsma JB, Carlier IV, Vries MH, Gersons BP. Treatment of acute posttraumatic stress disorder with brief cognitive behavioural therapy: a randomised controlled trial. American Journal of Psychiatry 2007;164:82‐90. - PubMed
Skogstad 2015 {published data only}
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Turpin 2005 {published data only}
    1. Turpin G, Downs M, Mason S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). British Journal of Psychiatry 2005;187(1):76‐82.
van Emmerik 2008 {published and unpublished data}
    1. Emmerik AA, Kamphuis JH, Emmelkamp PM. Treating acute stress disorder and posttraumatic stress disorder with cognitive behavioural therapy or structured writing therapy: a randomised controlled trial. Psychotherapy and Psychosomatics 2008;77(2):93‐100. - PubMed
Wagner 2007 {published and unpublished data}
    1. Wagner AW, Zatzick DF, Ghesquiere A, Jurkovoich GJ. Behavioral activation as an early intervention for posttraumatic stress disorder and depression. Cognitive and Behavioral Practice 2007;14(4):341‐9.
Wu 2014 {published and unpublished data}
    1. Wu KK, Li FW, Cho VW. A randomized controlled trial of the effectiveness of brief‐CBT for patients with symptoms of posttraumatic stress following a motor vehicle crash. Behavioural and Cognitive Psychotherapy 2014;42(1):31‐47. - PubMed
Zatzick 2004 {published and unpublished data}
    1. Zatzick D, Roy‐Byrne P, Russo J, Rivara F, Droesch R, Wagner A, et al. A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Archives of General Psychiatry 2004;61(5):498‐506. - PubMed
Zatzick 2013 {published data only}
    1. Osenbach JE, Lewis C, Rosenfeld B, Russo J, Ingraham LM, Peterson R, et al. Exploring the longitudinal trajectories of posttraumatic stress disorder in injured trauma survivors. Psychiatry 2014;77(4):386‐97. [DOI: 10.1521/psyc.2014.77.4.386] - DOI - PubMed
    1. Zatzick D, Jurkovich G, Rivara FP, Russo J, Wagner A, Wang J, et al. A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors. Annals of Surgery 2013;257(3):390‐9. - PMC - PubMed
Zatzick 2015 {published data only}
    1. Darnell D, O'Connor S, Wagner A, Russo J, Wang J, Ingraham L, et al. Enhancing the reach of cognitive‐behavioral therapy targeting posttraumatic stress in acute care medical settings. Psychiatric Services 2017;68(3):258‐63. - PubMed
    1. Zatzick D, O'Connor SS, Russo J, Wang J, Bush N, Love J, et al. Technology‐enhanced stepped collaborative care targeting posttraumatic stress disorder and comorbidity after injury: a randomized controlled trial. Journal of Traumatic Stress 2015;28(5):391‐400. - PMC - PubMed

References to studies awaiting assessment

Cairns 2018 {published data only}
    1. Cairns PL. Prevention of post intensive care syndrome‐family with sensation awareness focused training intervention: a randomized controlled trial pilot study. Dissertation Abstracts International: Section B: the Sciences and Engineering 2018;79(10‐B(E)).
Cox 2018b {published data only}
    1. Cox CE, Hough C, Jones D, Ungar A, Reagan W, Key MD, et al. Effect of a self‐directed mobile app mindfulness program for ICU survivors: a pilot RCT. American Journal of Respiratory and Critical Care Medicine 2018;197:A6185.
    1. Cox CE, Hough CL, Jones DM, Ungar A, Reagan W, Key MD, et al. Effects of mindfulness training programmes delivered by a self‐directed mobile app and by telephone compared with an education programme for survivors of critical illness: a pilot randomised clinical trial. Thorax 2018;74(1):33‐42. - PMC - PubMed
Guest 2018 {published data only}
    1. Guest R, Tran Y, Gopinath B, Cameron ID, Craig A. Psychological distress following a motor vehicle crash: preliminary results of a randomised controlled trial investigating brief psychological interventions. Trials 2018;19(1):343. - PMC - PubMed
Kilpatrick 1984 {published data only}
    1. Kilpatrick DG, Veronen LJ. Treatment of rape‐related problems: crisis intervention is not enough. In: Cohen L, Claiborn W, Specter G editor(s). Crisis Intervention: Community‐Clinical Psychology Series. Second Edition. New York (NY): Human Services Press, 1984.
Kredentser 2018 {published data only}
    1. Kredentser MS, Blouw M, Marten N, Sareen J, Bienvenu OJ, Ryu J, et al. Preventing posttraumatic stress in ICU survivors: a single‐center pilot randomized controlled trial of ICU diaries and psychoeducation. Critical Care Medicine 2018;46(12):1914‐22. - PubMed
Michelson 2018 {published data only}
    1. Michelson K, Rychlik K, Ciolino J, Martinez E, Persell S, Fragen P, et al. A randomized trial in the PICU comparing a communication intervention with an informational brochure. Critical Care Medicine 2018;46(Suppl 1):418.
Navidian 2017 {published data only}
    1. Navidian A, Saravani Z, Shakiba M. Impact of psychological grief counseling on the severity of post‐traumatic stress symptoms in mothers after stillbirths. Issues in Mental Health Nursing 2017;38(8):650‐4. - PubMed
Nielsen 2019 {published data only}
    1. Nielsen AH, Angel S, Egerod I, Hansen TB. The effect of diaries written by relatives for intensive care patients on posttraumatic stress (DRIP study): protocol for a randomized controlled trial and mixed methods study. BMC Nursing 2018;17:37. - PMC - PubMed
    1. Nielsen AH, Angel S, Egerod I, Lund TH, Renberg M, Hansen TB. The effect of family‐authored diaries on posttraumatic stress disorder in intensive care unit patients and their relatives: a randomised controlled trial (DRIP‐study). Australian Critical Care 2019;19:19. - PubMed
Rodin 2019 {published data only}
    1. Rodin G, Malfitano C, Rydall A, Schimmer A, Marmar CM, Mah K, et al. Emotion And Symptom‐focused Engagement (EASE): a randomized phase II trial of an integrated psychological and palliative care intervention for patients with acute leukemia. Support Care Cancer 2019 Apr 17 [Epub ahead of print]. [DOI: 10.1007/s00520-019-04723-2] - DOI - PubMed
Sun 2018 {published data only}
    1. Sun S, Li J, Ma Y, Bu H, Luo Q, Yu X. Effects of a family‐support programme for pregnant women with foetal abnormalities requiring pregnancy termination: a randomized controlled trial in China. International Journal of Nursing Practice 2018;24(1):e12614. - PubMed
Wade 2019 {published data only}
    1. Richards‐Belle A, Mouncey PR, Wade D, Brewin CR, Emerson LM, Grieve R, et al. Psychological Outcomes following a nurse‐led Preventative Psychological Intervention for critically ill patients (POPPI): protocol for a cluster‐randomised clinical trial of a complex intervention. BMJ Open 2018;8(2):e020908. - PMC - PubMed
    1. Wade DM, Mouncey PR, Richards‐Belle A, Wulff J, Harrison DA, Sadique MZ, et al. Effect of a nurse‐led preventive psychological intervention on symptoms of posttraumatic stress disorder among critically ill patients: a randomized clinical trial. JAMA 2019;321(7):665‐75. - PMC - PubMed
    1. Wulff J, Sadique Z, Grieve R, Howell D, Mouncey P, Wade D, et al. Psychological outcomes following a nurse‐led preventative psychological intervention for critically ill patients trial: statistical and health economic analysis plan. Journal of the Intensive Care Society 2018;19(4):281‐6. - PMC - PubMed
Wendlandt 2019 {published data only}
    1. Carson SS, Cox CE, Wallenstein S, Hanson LC, Danis M, Tulsky JA, et al. Effect of palliative care‐led meetings for families of patients with chronic critical illness: a randomized clinical trial. JAMA 2016;316(1):51‐62. - PMC - PubMed
    1. Wendlandt B, Ceppe A, Choudhury S, Cox CE, Hanson LC, Danis M, et al. Modifiable elements of ICU supportive care and communication are associated with surrogates' PTSD symptoms. Intensive Care Medicine 2019;45(5):619‐26. - PMC - PubMed

References to ongoing studies

ISRCTN39318241 {published data only}
    1. Sjomark J, Parling T, Jonsson M, Larsson M, Skoog Svanberg A. A longitudinal, multi‐centre, superiority, randomized controlled trial of Internet‐based cognitive behavioural therapy (iCBT) versus treatment‐as‐usual (TAU) for negative experiences and posttraumatic stress following childbirth: the JUNO study protocol. BMC Pregnancy and Childbirth 2018;18(1):387. - PMC - PubMed
NCT02085512 {published data only}
    1. Fine NB, Achituv M, Etkin A, Merin O, Shalev AY. Evaluating web‐based cognitive‐affective remediation in recent trauma survivors: study rationale and protocol. European Journal of Psychotraumatology 2018;9(1):1442602. - PMC - PubMed
NCT02591472 {published data only}
    1. Zdziarski‐Horodyski L, Horodyski M, Sadasivan KK, Hagen J, Vasilopoulos T, Patrick M, et al. An integrated‐delivery‐of‐care approach to improve patient reported physical function and mental wellbeing after orthopedic trauma: study protocol for a randomized controlled trial. Trials 2018;19(1):32. - PMC - PubMed
NCT03438175 {published data only}
    1. NCT03438175. Intensiva 2.0: improve the communication towards families of critically ill patients. clinicaltrials.gov/show/NCT03438175 (first received 19 February 2018).
NCT03496714 {published data only}
    1. NCT03496714. Online psychoeducation for the prevention of PTSD. clinicaltrials.gov/show/NCT03496714 (first received 12 April 2018).
NCT03652298 {published data only}
    1. NCT03652298. Effects of a neuroscience‐based technique on post‐traumatic stress disorder symptoms, inflammation, and survival in cancer patients announced of a palliative disease progression and their partners. clinicaltrials.gov/show/nct03652298 (first received 29 August 2018).
Wells 2018 {published data only}
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