Do early interventions prevent PTSD? A systematic review and meta-analysis of the safety and efficacy of early interventions after sexual assault

Figures & data

Figure 1. Flow diagram of the study selection process. PTSD = Posttraumatic stress disorder. Adapted from ‘preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement’ (Moher, Liberati, Tetzlaff, Altman, & the PRISMA group, 2009).

Table 1. Characteristics of included studies.

Citation	Country	Setting	N in analysis	Participant characteristics	Main inclusion criteria	Main exclusion criteria	Interventions	Sessions
Echeburúaet al. (1996)	Spain	Seeking treatment at psychological counselling centres	20	Females Age: 22 yrs SD = 6.9	Sexual aggression < 3 months Meeting DSM-III-R criteria for PTSD	Severe mental illness Severe physical illness	Cognitive restructuring, coping skills training and progressive muscular relaxation training vs. progressive muscular relaxation training	5 weekly 60-minute sessions
Resnicket al. (2007)	USA	Seeking forensic examination at an academic medical centre	140	Females Age: 26.1 yrs SD = 9.8	Sexual assault < 72 hours	Severe mental illness Severe physical illness Intoxication Intellectual disability	Pre-examination video intervention vs. standard care	Single 17-minute video
Rothbaumet al. (2012)	USA	Public hospital emergency department	47	65% females Age: 31.5 yrs SD NR	Trauma < 72 hours	Intoxication No memory of event	Modified prolonged exposure session vs. standard care	3 weekly 60-minute sessions
Tarquinio et al. (2012a)	France	Via research centre, family doctor or regional victim aid associations	17^a	Females Age: 32.2 yrs SD = 9.1	Sexual trauma 24–72 hours ago First time Filed police complaint	Severe mental illness Severe physical illness Intoxication Intellectual disability	Newly integrated EMDR protocol	Single 113-minute session
Tarquinio et al. (2012b)	France	Referral via psychologists of regional victim aid associations	6^a	Females Age: 33.8 yrs SD = 7.4	Sexual assault 8–12 weeks ago By intimate partner Filed police complaint No previous similar trauma	Severe mental illness Severe physical illness Intoxication Intellectual disability	Standard EMDR treatment protocol according to Shapiro (2001)	3–4 weekly 60-minute sessions
Milleret al. (2015)	USA	Via specialized nurse examiners at local hospital	69–74^b	Females Age: 28.8 yrs SD = 10.5	Sexual assault < 72 hours	Severe mental illness Severe physical illness Intoxication Intellectual disability No memory of event	Postexamination video intervention + standard care vs. standard care	Single 9-minute video
Nixonet al. (2016)	Australia	Seeking treatment at a rape and sexual assault crisis centre	46^c	Females Age: 31.3 yrs SD = NR	Rape or sexual assault < 1 month Meeting criteria for ASD	Severe mental illness Intoxication Intellectual disability	Cognitive processing therapy vs. standard care	6 weekly 90-minute sessions

SD = standard deviation, NR = not reported, vs. = versus, DSM-III-R = Diagnostic and Statistical Manual of Mental Disorders third edition revised, ASD = acute stress disorder. ^a Initial sample size and drop-out rates not reported. ^b Depending on follow up. ^c Using multiple imputation by chained equations.

Figure 2. Risk of bias summary of included studies. The minus sign represents a high risk of bias, the plus sign a low risk of bias, and the question mark an unclear risk of bias. Produced using Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.

Table 2. Effects of interventions of included studies.

Citation	Follow-up	Outcome measure	Within-group analysis in intervention group	Between-group analysis
Echeburúa et al. (1996)	Posttreatment 1, 3, 6, 12 mth	PSS-I	Significant decrease in PTSD scores in both cognitive restructuring and progressive muscular relaxation groups.	Significantly lower PTSD scores in the cognitive restructuring group than in the progressive muscular relaxation group.
Resnick et al. (2007)	6 wks 6 mth	PSS-SR	No baseline data collected.	No significant difference in PTSD scores between the video intervention and standard care.
Rothbaum et al. (2012)	4, 12 wks	PSS-I	No baseline data reported for rape victims separately.	Significantly lower PTSD scores in the modified prolonged exposure session compared to assessment only.
Tarquinio et al. (2012a)	Pretreatment Posttreatment 4 wks, 6 mth	IES	Significant decrease in PTSD scores in EMDR participants.	Only one intervention, thus no between-group analysis.
Tarquinio et al. (2012b)	Pretreatment Posttreatment	IES	Significant decrease in PTSD scores in EMDR participants.	Only one intervention, thus no between-group analysis.
Miller et al. (2015)	Pretreatment 2 wks, 2 mth	PSS-SR	Significant increase in PTSD scores at 2-wks follow-up, but not at 2-mth follow-up.^a	No significant difference in PTSD scores between the video intervention and standard care.
Nixon et al. (2016)	Pretreatment 1 wk 3, 6, 12 mth	CAPS	Significant decrease in PTSD scores in the cognitive processing.	Between-group differences remained stable across treatment, indicating that there was no difference between cognitive processing therapy and standard care.

mth = month(s), PSS-I = PTSD Symptom Scale Interview, PTSD = Posttraumatic Stress Disorder, wks = weeks, PSS-SR = PTSD Symptom Scale Self-Report, NR = not reported, IES = Impact of Events Scale, EMDR = Eye Movement Desensitization and Reprocessing, wk = week, CAPS = Clinician-Administered PTSD Scale. ^aWithin-group analysis calculated from reported means and standard deviations at pretreatment and follow-up assessments.

Figure 3. Forest plot of comparison: intervention versus standard care. Outcome: severity of PTSD symptoms at first follow-up. The first follow-up post-intervention was: for Resnick et al. (2007) six weeks, for Rothbaum et al. (2012) 4 weeks, for Miller et al. (2015) 2 weeks and for Nixon et al. (2016) 1 week. Produced using Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.

Figure 4. Forest plot of comparison: intervention versus standard care. Outcome: severity of PTSD symptoms at latest follow-up. The latest follow-up was: for Resnick et al. (2007) 6-months post-intervention, for Rothbaum et al. (2012) 12 weeks, for Miller et al. (2015) 2 months and for Nixon et al. (2016) 1 year. Produced using Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.

Table B1. Risk of bias of Echeburúa et al. (1996).

Bias item	Authors’ judgement	Support for judgement
Random sequence generation	High risk	‘in order of arrival’ (p.189)
Allocation concealment	High risk	Since allocation was based on order of arrival, there cannot have been allocation concealment.
Blinding of participants	High risk	No blinding.
Blinding of outcome assessment	High risk	The same therapist carried out therapy and assessment.
Incomplete outcome data	Low risk	No drop-outs or treatment changes.
Selective reporting	Low risk	All data seem to be reported.

Table B2. Risk of bias of Resnick et al. (2007).

Bias item	Authors’ judgement	Support for judgement
Random sequence generation	High risk	Participants presenting on nonprime dates were assigned to the video condition, those on prime dates to the control group.
Allocation concealment	High risk	‘Project assistants were aware of the designated study condition prior to recruiting participants.’ (p.2435)
Blinding of participants	High risk	No blinding.
Blinding of outcome assessment	Low risk	‘The interviewer was blind to treatment condition throughout the course of the study.’ (p.2438)
Incomplete outcome data	High risk	As treated analysis, while 15 participants chose not to watch the video and 5 participants watched less than half after randomization.
Selective reporting	Low risk	All data seem to be reported.

Table B3. Risk of bias of Rothbaum et al. (2012).

Bias item	Authors’ judgement	Support for judgement
Random sequence generation	Low risk	Computer-generated patient random assignments.
Allocation concealment	Low risk	‘Envelopes containing … assignments were given to the patient and their nurse … to ensure that assessors remained blind’. (p.958)
Blinding of participants	High risk	No blinding.
Blinding of outcome assessment	Low risk	‘Blinded assessors administered’ (p.958)
Incomplete outcome data	Low risk	‘Missing values for week 4 and week 12 were handled with multiple imputation’ (p.959)
Selective reporting	Low risk	All data seem to be reported.

Table B4. Risk of bias of Tarquinio et al. (2012a).

Bias item	Authors’ judgement	Support for judgement
Random sequence generation	N/A
Allocation concealment	N/A
Blinding of participants	N/A
Blinding of outcome assessment	N/A
Incomplete outcome data	Uncertain risk	No data on participant selection and/or drop-outs.
Selective reporting	Low risk	All data seem to be reported.

Table B5. Risk of bias of Tarquinio et al. (2012b).

Bias item	Authors’ judgement	Support for judgement
Random sequence generation	N/A
Allocation concealment	N/A
Blinding of participants	N/A
Blinding of outcome assessment	N/A
Incomplete outcome data	Uncertain risk	No data on participant selection and/or drop-outs.
Selective reporting	Low risk	All data seem to be reported.

Table B6. Risk of bias of Miller et al. (2015).

Bias item	Authors’ judgement	Support for judgement
Random sequence generation	Uncertain risk	Randomization procedure not explained.
Allocation concealment	Uncertain risk	Allocation concealment not reported.
Blinding of participants	High risk	No blinding.
Blinding of outcome assessment	Low risk	‘trained research assistants, blind to the study condition’ (p.132)
Incomplete outcome data	High risk	As treated analysis with 50–64% drop-out rates.
Selective reporting	High risk	Results are only reported according to previous assault status.

Table B7. Risk of bias of Nixon et al. (2016).

Bias item	Authors’ judgement	Support for judgement
Random sequence generation	High risk	‘sequentially randomized (1:1 ratio)’ (p.238)
Allocation concealment	High risk	Since allocation was sequential there cannot have been allocation concealment.
Blinding of participants	High risk	No blinding
Blinding of outcome assessment	Low risk	‘Assessor … were unaware … of treatment condition’ (p.238)
Incomplete outcome data	Low risk	Many missing data, but imputed using appropriate methods.
Selective reporting	Low risk	All data seem to be reported.

Moher, S., Liberati, A., Tetzlaff, J., & Altmann, D. G.; The PRISMA Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine, 6(7), e1000097.

 Web of Science ®Google Scholar

Echeburúa, E., de Corral, P., Sarasua, B., & Zubizarreta, I. (1996). Treatment of acute posttraumatic stress disorder in rape victims: An experimental study. Journal of Anxiety Disorders, 10(3), 185–199.

 Web of Science ®Google Scholar

Resnick, H., Acierno, R., Waldrop, A. E., King, L., King, D., Danielson, C., … Kilpatrick, D. (2007). Randomized controlled evaluation of an early intervention to prevent post rape psychopathology. Behaviour Research and Therapy, 45(10), 2432–2447.

 Web of Science ®Google Scholar

Rothbaum, B. O., Kearns, M. C., Price, M., Malcoun, E., Davis, M., Ressler, K. J., … Houry, D. (2012). Early intervention may prevent the development of posttraumatic stress disorder: A randomized pilot civilian study with modified prolonged exposure. Biological Psychiatry, 72(11), 957–963.

 PubMed Web of Science ®Google Scholar

Tarquinio, C., Brennstuhl, M. J., Reichenbach, S., Rydberg, J. A., & Tarquinio, P. (2012a). Early treatment of rape victims: Presentation of an emergency EMDR protocol. Sexologies, 21(3), 113–121.

 Google Scholar

Tarquinio, C., Schmitt, A., Tarquinio, P., Rydberg, J. A., & Spitz, E. (2012b). Benefits of “eye movement desensitization and reprocessing” psychotherapy in the treatment of female victims of intimate partner rape. Sexologies, 21(2), 60–67.

 Google Scholar

Shapiro, F. (2001). Eye movement desensitization and reprocessing (EMDR): Basic principles, protocols, and procedures. New York: Guilford Press.

 Google Scholar

Miller, K. E., Cranston, C. C., Davis, J. L., Newman, E., & Resnick, H. (2015). Psychological outcomes after a sexual assault video intervention: A randomized trial. Journal of Forensic Nursing, 11(3), 129–136.

 Web of Science ®Google Scholar

Nixon, R. D., Best, T., Wilksch, S. R., Angelakis, S., Beatty, L. J., & Weber, N. (2016). Cognitive processing therapy for the treatment of acute stress disorder following sexual assault: A randomised effectiveness study. Behaviour Change, 33(4), 232–250.

 Web of Science ®Google Scholar