In the Journals

Psychotherapeutic, combined treatments superior to pharmacological treatment in PTSD

Results from meta-analyses showed that long-term benefits of psychotherapeutic and combined treatments were superior to pharmacological treatments for PTSD across six randomized clinical trials with follow-up data.

The available evidence appears not to support using pharmacological therapy as first-line treatment for PTSD, researchers wrote in JAMA Psychiatry.

“Treatment guidelines typically recommend different types of trauma-focused psychotherapeutic treatments as first-line PTSD treatment. Concerning pharmacological therapies, however, recommendations are inconsistent,” Jasmin Merz, MSc, from the division of clinical psychology and psychotherapy, University of Basel, Switzerland, and colleagues wrote. “Although combination or augmentation treatment strategies have been suggested as promising and exciting new developments, it remains uncertain whether benefit increases when combining pharmacological and psychotherapeutic treatments.”

Researchers conducted a systematic review and network meta-analysis to compare the benefits and acceptability of psychotherapeutic vs. pharmacological treatments and their combinations in in adults with PTSD.

After searching online clinical databases for relevant studies, they identified 12 randomized clinical trials (RCTs) comprising 922 participants, which contributed 23 direct comparisons between psychotherapeutic and pharmacological treatments or their combinations. They collected standardized mean differences (SMDs) and ORs using random-effects network and pairwise meta-analyses.

At the end of treatment, Merz and colleagues found that no treatment approach was superior. However, at longest available follow-up, psychotherapeutic treatments showed greater benefit than pharmacological treatments in network meta-analysis (SMD = –0.83; 95% CI, –1.59 to –0.07) and pairwise meta-analysis (SMD = –0.63; 95% CI, –1.18 to –0.09) meta-analyses.

Both network meta-analysis showed that combined treatments were more beneficial than pharmacological treatments alone (SMD = –0.96; 95% CI, –1.87 to –0.04), but this was not shown in pairwise meta-analysis (SMD = –1.02; 95% CI, –2.77 to 0.72).

The results indicated no difference between combined treatments and psychotherapeutic treatments at long-term follow-up. In addition, there was no significant differences between the three treatment approaches regarding treatment acceptability.

“Our results confirm the recommendations of many treatment guidelines, that psychotherapeutic treatments should be preferred as first-line treatments, and we found limited evidence to recommend pharmacological treatments as monotherapies, when sustained and long-term symptom improvement is intended,” Merz and colleagues wrote.

Image of Sonya B. Norman
Sonya Norman

Future research needs to address clinically meaningful questions, like what clinicians can do when the first treatment fails, not just the question of whether psychotherapy or pharmacotherapy is better, Murray B. Stein, MD, MPH, and Sonya B. Norman, PhD, from the department of psychiatry, University of California San Diego, wrote in an editorial.

“What is most needed to help break through this therapeutic impasse is a monumental effort to prioritize and fund PTSD clinical trials and trial consortia, so that the size, quality and number of trials can feed a robust set of quality meta-analytic results to the whale shark of evidence-based medicine — the systemic review of meta-analyses,” they wrote. – by Savannah Demko

Disclosures: Merz reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Stein reports numerous disclosures; please see the editorial.

Results from meta-analyses showed that long-term benefits of psychotherapeutic and combined treatments were superior to pharmacological treatments for PTSD across six randomized clinical trials with follow-up data.

The available evidence appears not to support using pharmacological therapy as first-line treatment for PTSD, researchers wrote in JAMA Psychiatry.

“Treatment guidelines typically recommend different types of trauma-focused psychotherapeutic treatments as first-line PTSD treatment. Concerning pharmacological therapies, however, recommendations are inconsistent,” Jasmin Merz, MSc, from the division of clinical psychology and psychotherapy, University of Basel, Switzerland, and colleagues wrote. “Although combination or augmentation treatment strategies have been suggested as promising and exciting new developments, it remains uncertain whether benefit increases when combining pharmacological and psychotherapeutic treatments.”

Researchers conducted a systematic review and network meta-analysis to compare the benefits and acceptability of psychotherapeutic vs. pharmacological treatments and their combinations in in adults with PTSD.

After searching online clinical databases for relevant studies, they identified 12 randomized clinical trials (RCTs) comprising 922 participants, which contributed 23 direct comparisons between psychotherapeutic and pharmacological treatments or their combinations. They collected standardized mean differences (SMDs) and ORs using random-effects network and pairwise meta-analyses.

At the end of treatment, Merz and colleagues found that no treatment approach was superior. However, at longest available follow-up, psychotherapeutic treatments showed greater benefit than pharmacological treatments in network meta-analysis (SMD = –0.83; 95% CI, –1.59 to –0.07) and pairwise meta-analysis (SMD = –0.63; 95% CI, –1.18 to –0.09) meta-analyses.

Both network meta-analysis showed that combined treatments were more beneficial than pharmacological treatments alone (SMD = –0.96; 95% CI, –1.87 to –0.04), but this was not shown in pairwise meta-analysis (SMD = –1.02; 95% CI, –2.77 to 0.72).

The results indicated no difference between combined treatments and psychotherapeutic treatments at long-term follow-up. In addition, there was no significant differences between the three treatment approaches regarding treatment acceptability.

“Our results confirm the recommendations of many treatment guidelines, that psychotherapeutic treatments should be preferred as first-line treatments, and we found limited evidence to recommend pharmacological treatments as monotherapies, when sustained and long-term symptom improvement is intended,” Merz and colleagues wrote.

Image of Sonya B. Norman
Sonya Norman

Future research needs to address clinically meaningful questions, like what clinicians can do when the first treatment fails, not just the question of whether psychotherapy or pharmacotherapy is better, Murray B. Stein, MD, MPH, and Sonya B. Norman, PhD, from the department of psychiatry, University of California San Diego, wrote in an editorial.

“What is most needed to help break through this therapeutic impasse is a monumental effort to prioritize and fund PTSD clinical trials and trial consortia, so that the size, quality and number of trials can feed a robust set of quality meta-analytic results to the whale shark of evidence-based medicine — the systemic review of meta-analyses,” they wrote. – by Savannah Demko

Disclosures: Merz reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Stein reports numerous disclosures; please see the editorial.