Featured review: Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD)

Updated review: Internet‐based cognitive and behavioural therapies for post‐traumatic stress disorder (PTSD) in adults

Why was this review important?

Post-traumatic stress disorder, or PTSD, is a common mental illness that can occur after a serious traumatic event. Symptoms include re-experiencing the trauma as nightmares, flashbacks, and distressing thoughts; avoiding reminders of the traumatic event; experiencing negative changes to thoughts and mood; and hyperarousal, which includes feeling on edge, being easily startled, feeling angry, having difficulties sleeping, and problems concentrating. PTSD can be treated effectively with talking therapies that focus on the trauma. Some of the most effective therapies are those based on cognitive behavioural therapy (CBT). Unfortunately, there are a limited number of qualified therapists who can deliver these therapies. There are also other factors that limit access to treatment, such as the need to take time off work to attend appointments, and transportation issues.

An alternative is to deliver psychological therapy on the Internet, with or without guidance from a therapist. Internet-based cognitive and behavioural therapies (I-C/BT) have received a great deal of attention and are now used routinely to treat depression and anxiety. There have been fewer studies of I-C/BT for PTSD, yet research is expanding and there is a growing evidence base for their efficacy.

We spoke to lead author; Natalie Simpson who said "We’re living through unprecedented times, and whilst we cannot yet be sure of the full impact of the COVID-19 pandemic, an increase in PTSD lived experience is expected. Literature highlights the COVID-19 pandemic as a turning point for increased e-Health, though a drive towards improving access to psychological therapies was of course evident pre-pandemic, with an increasing number of internet-based interventions in use to treat mental health conditions, including PTSD.

The findings of this review are therefore important to understand the growing evidence base of internet-based therapies for PTSD, and particularly timely given the necessities to provide ‘COVID-proof’ treatment options, and alternatives to face-to-face therapies.  The efficacy of internet-based cognitive and behavioural therapies for PTSD is evident, with guided, rather than non-guided interventions, and trauma-focused, rather than non-trauma-focused interventions, found to be more effective in reducing PTSD symptoms.

Further studies are however needed and it was encouraging to find many planned and ongoing studies."

Who will be interested in this review?

  • People with PTSD and their families and friends
  • Professionals working in mental health services
  • General practitioners
  • Commissioners

What questions did this review try to answer?

In adults with PTSD, we tried to find out if I-C/BT:

  • was more effective than no therapy (wait list);
  • was as effective as psychological therapies delivered by a therapist;
  • was more effective than other psychological therapies delivered online; or
  • was more effective than education about the condition delivered online, at reducing symptoms of PTSD, and improving quality of life; or
  • was cost effective, compared to face-to-face therapy?

Which studies did the review include?

We searched for randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) that examined I-C/BT for adults with PTSD, published between 1970 and 5 June 2020.

We included 13 studies with 808 participants.

What did the evidence from the review tell us?

  • Analyses including 10 studies found that I-C/BT was more effective than no therapy (waiting list), at reducing PTSD. However, the quality of the evidence was very low, which means we have very little confidence in this finding.
  • Analyses including two studies found there was no difference between I-C/BT and another type of psychological therapy delivered online. However, the quality of the evidence was very low, which means we have very little confidence in this finding.
  • One study found that face-to-face non-CBT was more effective than I-C/BT. However, baseline levels of PTSD symptoms were not controlled for and the quality of this evidence was very low, which limits our confidence in this finding.
  • We found no studies using standardised or validated measures of acceptability to tell us whether people who received I-C/BT felt it was an acceptable treatment.
  • We found no studies that reported the cost-effectiveness of I-C/BT.

What should happen next?

The current evidence base is growing but still small. More studies are needed to decide if I-C/BT should be used routinely for the treatment of PTSD.