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Original Investigation
June 12, 2019

Comparative Efficacy and Acceptability of Pharmacological, Psychotherapeutic, and Combination Treatments in Adults With Posttraumatic Stress Disorder: A Network Meta-analysis

Author Affiliations
  • 1Division of Clinical Psychology and Psychotherapy, Department of Psychology, University of Basel, Basel, Switzerland
  • 2Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
JAMA Psychiatry. 2019;76(9):904-913. doi:10.1001/jamapsychiatry.2019.0951
Key Points

Question  Is there evidence for the superiority of pharmacological, psychotherapeutic, or combination treatment in treating adults with posttraumatic stress disorder?

Findings  This network meta-analysis including 12 randomized clinical trials comprising 922 participants with 23 comparisons demonstrated similar findings for the 3 approaches at the end of treatment, but long-term benefits of psychotherapeutic and combined treatments were superior to pharmacological treatments across 6 randomized clinical trials that reported follow-up data.

Meaning  The available evidence is sparse and appears not to support the use of pharmacological therapy as first-line treatment for posttraumatic stress disorder; furthermore, this study suggests that direct comparisons reporting long-term outcomes for all 3 types of therapy are needed.


Importance  Posttraumatic stress disorder (PTSD) is a prevalent mental disorder, with a high risk of chronicity, comorbidity, and functional impairment; PTSD is complicated to treat, and the debate on the best treatment approach is ongoing.

Objective  To examine comparative outcomes and acceptability of psychotherapeutic and pharmacological treatments and their combinations in adults with PTSD.

Data Sources  Embase, MEDLINE, PsycINFO, Cochrane Controlled Trials Register, and PSYNDEX were searched for studies published from January 1, 1980, to February 28, 2018. Reference lists of included studies and of previously published guidelines and systematic reviews were also searched.

Study Selection  Of 11 417 records identified, 12 published randomized clinical trials (RCTs) comprising 922 participants, contributing 23 direct comparisons between psychotherapeutic and pharmacological treatments or their combinations were included.

Data Extraction and Synthesis  Standardized mean differences (SMDs) and odds ratios were aggregated using random-effects network and pairwise meta-analyses. Risk of bias and indirectness was rated for each study, and network confidence was rated using the Confidence in Network Meta-Analysis framework.

Main Outcomes and Measures  The primary outcome was the comparative benefit between 2 treatment approaches to PTSD symptom improvement, and secondary outcome was the comparative acceptability of the treatment approaches, as indicated by patient dropout rates before treatment termination.

Results  No treatment approach was found to be superior at the end of treatment (for all, 95% CI included 0). At the last follow-up, psychotherapeutic treatments showed greater benefit than pharmacological treatments in both network (SMD, −0.83; 95% CI, −1.59 to −0.07) and pairwise (SMD, −0.63; 95% CI, −1.18 to −0.09, 3 RCTs) meta-analyses. No difference was found between combined treatments and psychotherapeutic treatments at long-term follow-up, and combined treatments were associated with better outcomes than pharmacological treatments in the network meta-analysis (SMD, −0.96; 95% CI, −1.87 to −0.04), but not in the pairwise meta-analysis, which included 2 RCTs (SMD, −1.02; 95% CI, −2.77 to 0.72). No evidence was found for differential acceptability of the 3 treatment approaches.

Conclusions and Relevance  These results suggest superiority of psychotherapeutic treatments over pharmacological treatments; network, but not pairwise, meta-analyses suggest superiority of combined treatments over pharmacological treatments in improving PTSD symptom severity in the long term. The scarcity of reported long-term findings hampers definite conclusions and demonstrates the need for robust evidence from large-scaled comparative trials providing long-term follow-up data.