Draft Key Questions
Disposition of Comments Report
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To assess efficacy, comparative effectiveness, and harms of psychological, pharmacological, and emerging interventions to prevent posttraumatic stress disorder (PTSD) in adults.
PubMed®, the Cochrane Library, CINAHL, Embase, PILOTS, International Pharmaceutical Abstracts, PsycINFO®, Web of Science, reference lists of published literature (from January 1, 1980, to July 30, 2012). In addition, we searched various sources for grey literature.
Two investigators independently selected, extracted data from, and rated risk of bias of relevant studies. If data were sufficient, we conducted quantitative analyses using random-effects models to estimate pooled effects. We graded strength of evidence (SOE) based on established guidance.
We included 19 trials with a range of populations exposed to a variety of psychological traumas. Participants suffered from symptoms of PTSD but did not meet diagnostic criteria for PTSD. For most interventions studied, we did not find reliable evidence to support efficacy for the prevention of PTSD or for the reduction of PTSD-related symptom severity. Evidence was sufficient to justify conclusions about three treatments. First, debriefing does not reduce either the incidence or the severity of PTSD or related psychological symptoms in civilian victims of crime, assault, or accident trauma (low SOE). Second, our meta-analyses of three trials showed that, in subjects with acute stress disorder, brief trauma-focused cognitive behavioral therapy (CBT) was more effective than supportive counseling (SC) in reducing the severity of PTSD (moderate SOE). Pooled results did not reach statistical significance for incidence of PTSD, depression symptom severity (both low SOE), and anxiety symptom severity (moderate SOE), but numerically favored CBT over SC. Finally, collaborative care for a traumatic injury requiring hospitalization produces a greater decrease in PTSD symptom severity at 6, 9, and 12 months after injury than does usual care (low SOE).
The efficacy of psychological interventions to prevent PTSD did not differ between men and women (low SOE). Evidence was insufficient to determine whether previous depression or a history of child abuse or baseline PTSD symptoms influence the effectiveness of interventions. Evidence was insufficient to determine the effect of timing, intensity, or dosing on the effectiveness or risk of harms of interventions or to justify conclusions about the comparative risk of harms. For emerging interventions such as yoga, dietary supplements, and complementary or alternative interventions, no studies met our eligibility criteria. Evidence was insufficient to determine whether any treatment approaches were more effective for victims of particular trauma types.
Evidence supporting the effectiveness of most interventions used to prevent PTSD is lacking. If available in a given setting, brief trauma-focused CBT might be the preferable choice for reducing PTSD symptom severity in persons with acute stress disorder and collaborative care might be preferred for trauma patients requiring surgical hospitalization; by contrast, debriefing appears to be an ineffective intervention to reduce symptoms and prevent PTSD.