Most Early Psychological Interventions Do Not Cut PTSD Risk
July 17, 2009 — Parachuting in therapists to counsel everyone exposed to a traumatic event has become almost routine as an attempt to prevent posttraumatic stress disorder (PTSD), but these early therapy sessions but may be doing more harm than good, according to a new Cochrane Database of Systematic Reviews published online July 8.
Neil P. Roberts, DClinPsy, a consultant clinical psychologist at the Traumatic Stress Service at the University Hospital of Wales, in Cardiff, and colleagues report that data from randomized controlled trials do not support routine use of any psychological intervention in asymptomatic subjects and that some people do worse with multiple-session interventions than with no intervention.
"The clear practice implication of this is that, at present, multiple-session interventions aimed at all individuals exposed to traumatic events should not be used," the reviewers conclude.
"There was no evidence of any intervention being effective at preventing PTSD for participants who had been exposed to a traumatic event regardless of any symptomatology," Dr. Roberts told Medscape Psychiatry.
"There was a trend toward more self-reported PTSD symptoms at 3 to 6 months vs no intervention. However, this was not an entirely consistent finding across other outcomes and so deserves some caution in terms of drawing conclusions and calls for further investigation. Also, the analysis includes data from studies using a number of different types of intervention, and it may be that certain interventions are harmful but others are not.
"For example, the group that received adapted debriefing intervention tended to do worse across a range of outcomes, as did the group that had counseling following an interpersonal psychotherapy model."
The reviewers' main objective was to examine the efficacy of multiple-session early psychological interventions begun within 3 months of a traumatic event at preventing PTSD. The review did not include the single-session individual/group psychological interventions known as "psychological debriefing," which a previous Cochrane review had found to be ineffective.
The meta-analysis included 8 randomized controlled trials of multiple-session early psychological intervention or treatment designed to prevent symptoms of PTSD. These included trials of integrated cognitive behavioral and family therapy, individual counseling, interpersonal counseling, group counseling, adapted debriefing, up to 6 sessions of cognitive behavioral therapy (CBT), and counseling and collaborative care.
The outcome variable was prevention of PTSD, defined as repeated experiencing of the trauma; avoidance of reminders and symptoms of numbing; and symptoms of heightened arousal.
"The main implication would seem to be that, as things stand, clinicians should not be offering routine preventative intervention to all survivors after a trauma or major incidents. We believe that these findings support the case for a more targeted approach, focusing on those who are symptomatic," Dr. Roberts said.
PTSD expert Alex Holmes, MBBS, MMed, senior lecturer and consultant psychiatrist at Royal Melbourne Hospital, in Australia, told Medscape Psychiatry that these data should not be overinterpreted.
"The current evidence would not support an approach whereby all persons exposed to traumatic events are given multisession psychological intervention with the aim of reducing the incidence of PTSD.
"The evidence should not be interpreted to mean that psychological interventions should not be used in the weeks after traumatic events, but rather their use needs to be targeted," Dr. Holmes said. He noted that research has yet to identify who should be targeted or when, but that symptomatic patients may benefit from early intervention.
"Although it may be the case that the wrong therapy at the wrong time may worsen a patient's outcome, this does not mean that general psychological concern and support in the course of nonpsychological care for injury is detrimental.
"In fact, the absence of such basic support may well have negative consequences, when looking at the robust evidence for the absence of support as a risk factor for PTSD," Dr. Holmes,
9/11 Data Show Benefit of Workplace Interventions
The Cochrane review included only randomized controlled trials, and that may be a problem in judging efficacy of interventions aimed at survivors of rare traumatic events.
Joseph A. Boscarino, PhD, senior investigator at the Henry Hood Center for Health Research of the Geisinger Clinic in Danville, Pennsylvania, and adjunct associate professor of medicine at Mount Sinai School of Medicine, in New York City, told Medscape Psychiatry that 2-year follow-up data from the World Trade Center Disaster Outcome Study agree with Dr. Roberts's finding that formal psychotherapy sessions were (at best) ineffective at preventing PTSD in New York City residents following the September 11, 2001 attacks, but that brief worksite interventions by trained professionals were effective.
"This is a hot area of controversy, but I believe it is too soon to write off early interventions. We need both more randomized controlled studies, such as those included in the Cochrane meta-analysis, and more observational studies," Dr. Boscarino said. "The populations included in randomized controlled trials may be so select that the results would not be applicable to the general population, so we need to consider both these results and results from observational studies."
One research design problem is that it is very difficult to do randomized controlled trials of interventions designed to prevent PTSD in a population exposed to trauma, because these are uncommon and unpredictable events.
Dr. Boscarino said that new funding from the US Department of Defense, the Department of Veterans' Affairs, and the National Institutes of Health should help researchers conducting new studies, as well as those attempting to replicate data from earlier intervention trials.
"I believe that well-done brief interventions right after the trauma exposure among those in need will prove the most cost-effective, but research is still needed to confirm this hypothesis, said Dr. Boscarino.
The authors report no relevant conflicts of interest.
Cochrane Database Syst Rev. 2009;3:CD006869. Abstract