Elsevier

Clinical Psychology Review

Volume 43, February 2016, Pages 1-16
Clinical Psychology Review

Internet-based interventions for posttraumatic stress: A meta-analysis of randomized controlled trials

https://doi.org/10.1016/j.cpr.2015.11.004Get rights and content

Highlights

  • CBT-IBIs reduce PTSD symptoms significantly at post-test compared to passive controls.

  • CBT-IBIs with different components are all more efficacious than passive controls.

  • CBT- and EW-IBIs are not superior to active control conditions.

  • Efficacy of CBT-IBIs is given at post-test, but does not carry through to follow-up.

  • However, the number of studies was low for sufficiently powered testing.

Abstract

Posttraumatic stress disorder (PTSD) is a prevalent and highly distressing affliction, but access to trauma-focused psychotherapy is limited. Internet-based interventions (IBIs) could improve the delivery of and access to specialized mental health care. Currently, no meta-analytical evidence is available on IBIs for PTSD. We conducted a meta-analysis of 20 randomized controlled studies, including 21 comparisons, in order to summarize the current state of efficacy for the treatment of PTSD and to identify moderator variables. Studies tested internet-based cognitive behavioral therapy (CBT) and expressive writing (EW) against active or passive comparison conditions, including subclinical and clinical samples. Results show that at post-assessment CBT-IBIs are significantly more efficacious than passive controls, resulting in medium to large effects on the PTSD sum and all sub-symptom scores (0.66 < g < 0.83), but both EW and CBT are not superior to active controls. EW differed from controls only at follow-up in reducing intrusions and hyperarousal, but based on merely two studies. Subgroup analyses reveal that for CBT none of the program components such as provision of therapeutic support, reminders, or number of sessions serves as a moderator. Overall, results for CBT-IBIs are promising, but the number of includable studies for subgroup analyses was low, limiting statistical power. Future research is necessary to systematically investigate the impact of treatment components and test against active controls with optimal power.

Introduction

Around 65% of the world population experience at least one potentially traumatic event at some point during the lifespan (National Collaborating Center for Mental Health, 2005). A recent survey of the lifetime occurrence of posttraumatic stress disorder (PTSD) in the US adult population found prevalence rates of 11.7% in women and 4% in men (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012). Depending on a number of risk factors such as an interpersonal nature of the traumatic event (Phelps et al., 2014), female gender (Kessler et al., 2012), repeated traumatic exposure for occupational reasons (e.g. Hoge, Castro, Messer, McGurk, Cotting and Koffman, 2004, Kessler, Sonnega, Bromet, Hughes and Nelson, 1995), residency in an unstable political and economic country (de Jong, Komproe, Van Ommeren, et al., 2001, Keane, Marshall and Taft, 2006), and being member of an ethnic minority (Ruwaard, Lange, Schrieken, & Emmelkamp, 2011), prevalence rates of lifetime PTSD have been found to vary between 5% and 55% (Terhakopian, Sinaii, Engel, Schnurr, & Hoge, 2008). In addition, due to repeated revisions of diagnostic criteria and a variety of available measures, reports on the prevalence of PTSD differ across studies despite comparable sample characteristics (Terhakopian et al., 2008).

Following the recently updated DSM-5 criteria (American Psychiatric Association, 2013), PTSD comprises four symptom clusters: (a) the avoidance of external and internal stimuli that may trigger traumatic memories; (b) the re-experiencing of the traumatic event in the form of intrusive thoughts, nightmares or flashbacks; (c) negative cognitions and mood, which is characterized by senses of blame, guilt or shame, estrangement, withdrawal and the inability to experience or to express positive emotions; and (d) alterations in arousal and reactivity (hyperarousal), that may lead to excessive alertness, aggressive behavior, recklessness, sleep disturbances, safety behavior and jumpiness. The previous version, DSM-IV-TR (American Psychiatric Association, 2013), on which most research is still based, includes three symptom clusters: avoidance, re-experiencing and hyperarousal.

Trauma-focused cognitive behavioral therapy (TF-CBT) combines well-established cognitive-behavioral techniques such as confrontation with trauma-associated stimuli (exposure in sensu or in vivo) with habituation and mental processing of the traumatic event as assumed mechanisms of change, and cognitive reappraisal, which specifically aims at the identification and modification of maladaptive cognitive distortions associated with PTSD. TF-CBT is the best evaluated approach for PTSD, resulting in the highest number of studies providing consistent evidence of efficacy with large effect sizes when compared to wait list or usual care (Bisson, Roberts, Andrew, Cooper and Lewis, 2013, Bradley, Greene, Russ, Dutra and Westen, 2014, Diehle, Schmitt, Daams, Boer and Lindauer, 2014).

However, although effective treatments for PTSD are available, these are not widely applied in clinical practice, leading to drawbacks concerning the clinical practice of evidence-based medicine in face-to-face psychotherapy for the treatment of PTSD (Bisson, Roberts, Andrew, Cooper and Lewis, 2013, Keller, Stevens, Lui, Murray and Yaggie, 2014, Kirkpatrick and Heller, 2014). Moreover, only a minority of traumatized individuals who experience symptoms of PTSD are in touch with the health care system (Kessler et al., 1999) and only around one in five patients seeks psychological treatment (Calhoun, Bosworth, Grambow, Dudley and Beckham, 2002, Hoge, Castro, Messer, McGurk, Cotting and Koffman, 2004, Rayburn, Wenzel, Elliott, Hambarsoomians, Marshall and Tucker, Roberts, Gilman, Breslau, Breslau and Koenen, 2011, Spoont, Murdoch, Hodges and Nugent, 2010), due to fear of stigmatization, embarrassment, judgment or exclusion (Hoge, Castro, Messer, McGurk, Cotting and Koffman, 2004, Hoge, Grossman, Auchterlonie, Riviere, Milliken and Wilk, 2014), or negative beliefs about mental health care services (Blais, Tsai, Southwick, & Pietrzak, 2015). Moreover, difficulties in establishing personal relationships can make it difficult for patients to open up during therapy (Besser and Neria, 2012, Campbell and Renshaw, 2013). Trauma survivors with PTSD often experience distress in interpersonal relationships, which can also affect the therapeutic relationship in terms of diminished trust and self-disclosure and enhance the fear of being emotionally flooded in therapy when recollecting the traumatic experience (Charuvastra & Cloitre, 2008). These difficulties with being vulnerable in the therapeutic context affect the benefit from the treatment. Above all, there is a pronounced lack of availability of psychotherapy for PTSD, with long waiting times and inadequate psychotherapy infrastructure (Trusz, Wagner, Russo, Love, & Zatzick, 2011). This disparity of need for psychotherapy and availability is crucial, and alternative means of providing access to treatment are needed, since PTSD severely affects life satisfaction as well as functioning and has a tendency to become chronic if untreated (Davidson, Stein, Shalev, & Yehuda, 2014).

Most internet-based interventions (IBIs) are psychological treatments, usually based on established approaches such as CBT that are delivered exclusively via the internet, and that provide participants with disorder-specific treatment modules on a weekly to biweekly basis (e.g. Ebert & Erbe, 2012). The unique characteristic of being independent from seeing a therapist face-to-face provides IBIs with the distinct advantages of being easily accessible, low-threshold and visually anonymous, highlighting the potential of IBIs to reach specific populations that might not otherwise seek treatment. Depending on the particular program, a range of complementary components can be found, e.g. activity planning, applied relaxation training and social skill training. In addition, multimedia components are often integrated, such as video/audio vignettes or interactive trainings (e.g. cognitive bias modification training), or reminder messages to the client after a particular time of absence (e.g. Ebert and Erbe, 2012, Eichenberg and Ott, 2012). Furthermore, they can be supported by remote contact to a therapist via chat, email or video-conference-systems. Or IBIs can be conceptualized as self-help programs with automated feedback offering only on-demand contact to a therapist in case of symptom deterioration, or technical support if the patient has trouble using the program.

Various IBIs exist for the treatment of PTSD. Interapy (Lange et al., 2000) is one well evaluated and widely accepted IBI CBT-based program (e.g. Ruwaard et al., 2011) that encompasses three main components: self-confrontation (exposure), cognitive restructuring, and social sharing/restoration by means of 11 structured writing assignments. During the self-confrontation assignments the client writes about his trauma in first person and present tense in order to confront himself with the event and his associated thoughts and feelings. During the cognitive restructuring assignments the client writes encouraging and supportive letters to a hypothetical friend who is experiencing the same or a comparable trauma with the aim of instilling new views about it, reflecting on positive aspects in the client's life, regaining a sense of control and detecting and correcting dysfunctional or automated thoughts, unrealistic beliefs and burdensome feelings. During the assignments of social sharing/restoration the client reflects in symbolic farewell letters to a significant other or alternatively to himself on the therapeutic process and on how to deal with the trauma in the future. A specially trained trauma-psychotherapist guides the client through the interventions and by remote communication provides supportive and encouraging written feedback after each module and on a weekly basis. Besides Interapy, there are other internet treatment programs based on TF-CBT that complement trauma exposure and cognitive restructuring with additional CBT interventions, such as stress management, guided imagery or relaxation (⁎Carpenter, Stoner, Schmitz, McGregor and Doorenbos, 2014, ⁎Litz, Engel, Bryant and Papa, 2007, ⁎Steinmetz, Benight, Bishop and James, 2012, Wang, Wang and Maercker, 2013). An alternative approach that has been transferred to the internet is expressive writing (EW), which is based on theories of emotional disclosure (e.g. Pennebaker, 1997) and encourages the patient to write in detail about the trauma and to disclose her feelings and thoughts associated with it. In contrast to CBT-based treatment programs, EW delivered via the internet is generally shorter in duration and mainly not manual-based, the writing assignments are rather unstructured and therapeutic support is not commonly provided. Nevertheless, both EW and CBT have in common the fact that they are based on writing assignments.

There is also a range of other treatments that rely on the use of media, e.g. the use of video conferencing between face-to-face therapy sessions. These can use computer software or CD-ROMs as well as new technology, such as virtual reality that creates a realistic three-dimensional virtual environment for the patient (Gonçalves, Pedrozo, Coutinho, Figueira and Ventura, 2012, McLay, Ram, Murphy, Spira, Wood, Wiederhold, et al., 2014, Motraghi, Seim, Meyer and Morissette, 2014). Generally, these treatments are not independent of face-to-face therapy, but rather accompany conventional therapy and are therefore not considered as IBIs.

Thus far, meta-analytical research evaluating IBIs for PTSD has not been done. We are aware of two recent meta-analyses (Bolton and Dorstyn, 2015, Sloan, Gallagher, Feinstein, Lee and Pruneau, 2011) that investigate the efficacy of technology assisted interventions for PTSD including virtual reality, CD-ROM accompanied interventions, video conferencing as well as internet-delivered programs. However, subsuming several technologies that in some cases combine conventional therapy with these technologies makes it impossible to evaluate the efficacy of the particular modes of delivery (e.g. Ebert and Erbe, 2012, Eichenberg and Ott, 2012). Furthermore, both include randomized controlled trials (RCTs) as well as uncontrolled and/or non-randomized trials, and restrict their data sets to CBT-based interventions, thereby omitting alternative approaches. To our knowledge, only one publication focusing on internet-delivered treatments has been produced, but rather as a qualitative review than a quantitative analysis (e.g. Herbert & Brunet, 2009), thus restricting the findings to a descriptive level. A number of meta-analyses have analyzed PTSD together with several other disorders (Cuijpers, Marks, van Straten, Cavanagh, Gega and Andersson, 2, Grist and Cavanagh, 2013, Reger and Gahm, 2009, Spek, Cuijpers, Nyklícek, Riper, Keyzer and Pop, 2007), making it impossible to specify the efficacy for PTSD.

A number of meta-analyses of IBIs for other disorders examine the role of particular program components on efficacy. These include the provision of therapeutic support (Andersson and Cuijpers, 2009, Cowpertwait and Clarke, 2013, Grist and Cavanagh, 2013, Richards and Richardson, 2012, Spek, Cuijpers, Nyklícek, Riper, Keyzer and Pop, 2007), the number of treatment sessions (Richards & Richardson, 2012), as well as the implementation of additional components such as reminder functions or multimedia (Cowpertwait & Clarke, 2013). However, the results are conflicting and more meta-analytical research is needed here. Furthermore, psychotherapy research has shown that manual-guidance of treatment significantly improves treatment outcome (Laska, Gurman, & Wampold, 2014), but this common factor has hardly been investigated in IBIs.

The aim of this study was to conduct a comprehensive meta-analysis of all RCTs that evaluate IBIs for the treatment of subclinical or clinical PTSD in the adult population. As diagnostic interviews and symptom measures in recent research on PTSD mostly still utilized the three-part definition of PTSD that includes avoidance, intrusion and hyperarousal according to the DSM-V-TR (American Psychiatric Association, 2000), we focused on these three symptom clusters. First, we aimed at evaluating the efficacy of IBIs using different therapeutic approaches with regard to both the global and the sub-symptom scales of avoidance, intrusion and hyperarousal. Second, we assess the role of particular program components for efficacy, namely the provision of therapeutic support, the number of intervention modules, standardization/manual use, and the use of reminder functions as well as of multimedia components. Third, we descriptively evaluate dropout and completer characteristics.

Section snippets

Inclusion criteria

Studies were required to meet the following inclusion criteria: 1) the program was an internet based intervention program; 2) the program aimed at reducing subclinical or clinical PTSD in an adult population; 3) results were reported at the PTSD sum and/or symptom cluster levels; 4) valid and reliable assessments were used; and 5) the study design was a RCT that compared an active intervention group to an active or passive comparison group by assessing symptom levels at least post treatment.

Literature search

The literature search identified 3312 records. Of these, 1750 were excluded because they were identified as duplicates, book chapters dealing with fundamentals and basic principles, editorials, guidelines, comments or corrections to other publications. From the remaining 1562 records 1525 were excluded after screening title and abstract for the following reasons: 732 did not target PTSD; 42 did not report on PTSD outcome, but rather used PTSD scores as covariates; 386 were identified as

Discussion

The findings of this meta-analysis provide support for the efficacy of CBT-IBIs in treating PTSD. Moderate to large effect sizes were found for PTSD global symptom severity as well as for the subscales for avoidance, intrusion and hyperarousal, when compared to passive control conditions. These findings are in line with a recent meta-analysis that demonstrated a large effect of telehealth interventions for PTSD compared to passive conditions (Sloan et al., 2011). Internet-based treatments also

Role of funding sources

No financial support has been received for this piece of work.

Contributors

CK gave the idea for this work. AK and CK discussed and decided about the inclusion and exclusion criteria and about which data bases were used. AK and HN conducted the literature search, screening and inclusion of articles, and discussed the results of the analyses. AK conducted the data extraction, analyses, and drafted the manuscript. AK conducted the calculations, and HN supervised the calculations, conducted the other changes requested by the reviewer for the first and second revision and

Conflict of interest

All authors declare no conflict of interest.

Acknowledgments

We want to highly thank Helen-Rose Cleveland, Sinclair Cleveland and Sebastian Burchert who helped in proof reading the article.

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    AK and HN have equally contributed and split first authorship.

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