Active duty and ex-serving military personnel with post-traumatic stress disorder treated with psychological therapies: systematic review and meta-analysis

Figures & data

Figure 1. Flow diagram for study selection.

Table 1. Characteristics of included studies.

Author & Country	Total Number Randomized & Theatre	Methods of recruitment	Method of diagnosis	Duration of therapy (weeks)	Experimental Interventions	Control Intervention	Relevant outcome measures	Follow-up period
Ahmadi et al. (2015) Iran	48 males active duty personnel (Iran)	VA Hospitals	SCID, DSM-III-R-PTSD-I	4 weeks	REM desensitization x 2 weekly (n = 16)	EMDR x 2 weekly (n = 16)	Mississippi PTSD scale, PSQI, DAQ	None
						& Wait list (n = 16)
Carlson et al. (1998) USA	35 male veterans (Vietnam)	VA Medical Centres & Community Veteran Centres	CAPS	12 weeks	EMDR (n = 10) vs Biofeedback-assisted relaxation (n = 13)	TAU (n = 12)	Mississippi PTSD scale, IES, STAI, BDI	3 months
Castillo et al. (2016) USA	86 female veterans (OEF/OIF)	VA mental & medical health out-patient clinic	CAPS	16 weeks	3-member TF-Group Therapy (n = 44)	Wait list (n = 42)	CAPS, SCID, LEC, SF-36, QOLI, PCL	6 months
Devilly et al. (1998) Australia	51 male veterans (Vietnam)	VA counselling service or Hospital outpatient clinic	DSM-III-R- PTSD-I	5 weeks	2 x EMDR (n = 19) vs EMDR without Eye Movements (n = 16)	TAU (n = 16)	Mississippi PTSD scale, IES, STAI, BDI, PPD, SUDs, COT	6 months
Foa et al. (2018) USA	370 active duty personnel & veterans (OEF/OIF)	Fort Hood, Military Base, Texas	PSS-I	8 weeks	Intensive PE (n = 110) vs weekly PE (n = 110) vs PCT (n = 110)	Minimal contact (n = 40)	PCL-S, VR-12	3 months
Forbes et al. (2012) Australia	59 veterans (2 female), (Vietnam, Timor, OEF)	Veterans & Veterans’ Families Counselling Service (VVCS)	CAPS	6 weeks	CPT (twice weekly) (n = 30)	Usual care (n = 29)	PCL, BDI-II, STAI-State, DAR-7, AUDIT, PTCI, ADAS, WHOQOL	3 months
Gamito et al. (2010) Portugal	10 male veterans (Africa)	Psychiatric out-patient clinic	CAPS	12 weeks	VR Exposure Therapy (n = 5) vs. Exposure in Imagination (n = 2)	Wait list (n = 3)	IES, SCL-90, BDI, ITC SOPI	None
Gray et al. (2017) USA	74 male veterans (Vietnam & OEF/OIF)	From adverts, personal referrals & clinicians	PSS-I	1 week	Reconsolidation Traumatic Memories (NLP) (n = 37)	Wait list (n = 37)	PCL-M	1.5 months
Jensen 1994 (Jensen, 1994) USA	25 male veterans (Vietnam)	VA Medical Centre, adverts, & direct contacts	SI-PTSD	2 weeks	2 sessions of EMDR (n = 13) (usually within 10 days)	Usual care (n = 12)	SUDs, VoC, GAS, M-PTSD	17 days
Keane et al. (1989) USA	24 veterans (Vietnam)	VA Medical Centre	DSM-III-PTSD-I	14 weeks	Implosive flooding (n = 11)	Wait list (n = 13)	PTSD subscale, BDI, STAI	4.5 months
McLay et al. (2011) USA	20 active duty military personnel (OEF/OIF)	Naval Medical Centre San Diego & Naval Hospital Camp Pendleton	CAPS	10 weeks	10 x VR-Graded Exposure (n = 10)	TAU (n = 10)	None	2.5 months
McLay et al. (2017) USA	81 active duty military personnel (OEF/OIF)	Naval Medical Centre San Diego & Marine Corp Base Camp Pendleton	CAPS	9 weeks	VR-Exposure Therapy (n = 43)	Exposure Therapy (n = 38)	None	3 months
Monson et al. (2006) USA	60 (6 women) (Korean, Vietnam & OEF/IOF)	VA Medical Centre	SCID-P, CAPs	10 weeks	12 x CPT twice weekly (n = 30)	Wait list (n = 30)	PCL, BDI, STAI, ACS	1 month
Peniston and Kulkosky (1991) USA	29 male veterans (Vietnam)	VA Medical Centre	DSM-III interview	4 weeks	30 x 30-min EEG alpha-beta brainwave training 5 x per week (n = 15)	TAU (n = 14)	MMPI	30 months
Rauch et al. (2015) USA	36 (3 female) veterans (OEF/OIF)	VA AAHS PTSD Clinical Team	MINI, CAPS	12 weeks	10-12 x 80 min sessions of PE (n = 18)	10-12 x 80 min sessions of PCT (n = 18)	PTCI	None
Ready et al. (2010) USA	11 veterans (Vietnam)	Atlanta VA Medical Centre’s Mental Health Clinic	SCID, CAPs	10 weeks	10 x sessions of VR-Exposure (n = 6)	10 x sessions of PCT (n = 5)	BDI	6 months
Reger et al. (2016) USA	162 Active duty military personnel (OEF/OIF)	Army Medical Centre or self-referred based via study advertisements	CAPs	10 Weeks	10 x 120 min sessions of PE (n = 54) vs VR-Exposure Therapy (n = 54)	Waiting list (n = 54)	PCL-C, BDI-II, BAI, SSRPH, IASMHS, CSQ	6 months
Resick et al. (2015) USA	108 Active duty military personnel (8 female) (OEF/OIF)	Fort Hood, Texas, military base	PSS-I, PCL-S	6 weeks	Group CPT (using CPT-C) (90-min groups twice weekly) (n = 56)	Group PCT (90-min groups twice weekly) (n = 52)	BDI-II	12 months
Resick et al. (2017) USA	268 Active duty military personnel (11 female) (OEF/OIF)	Fort Hood, Military Base, Texas	PSS-I, PCL-S	6 weeks	90 min x 2 weekly Group CPT (n = 133)	60 min x 2 weekly CPT delivered to individuals (n = 135)	BDI-II, BSSI	6 months
Sautter et al. (2015) USA	69 Veterans (OEF/OIF) & their partners	VA Family Mental Health Programme – New Orleans	CAPS, SCID	12 weeks	12 x weekly Structured Approach Therapy delivered to couples (n = 29)	12 x weekly PTSD Family Education delivered to couples (n = 28)	PCL, STAI, CES-D, DAS, ECR-R	3 months
Schnurr et al. (2003) USA	360 male veterans (Vietnam)	VA Medical Centres x 10	CAPS, SCID-P	30 weeks	30 x Weekly 1.5–2 hr TF-CBT group therapy, plus 5 x monthly, 15 min telephone booster sessions (n = 180)	30 x Weekly 1.5 hr Present-centred focused group CBT (n = 180)	GHQ-12, SF-36, QoL, GAF	12 months
Schnurr et al. (2007) USA	284 female veterans (n = 277) & Active duty personnel (n = 7)	9 x VA Medical Centres, 2 x VA Readjustment counselling centres, & 1 military hospital	CAPS	10 weeks	10 x weekly 90 min sessions of PE (Female therapists) (n = 141)	10 x weekly 90 min sessions of PCT (Female therapists) (n = 143)	SF36, SSAI, BDI, ASI, PTSD checklist	6 months
Suris et al. (2013) USA	86 male (n = 13) & female (n = 73) veterans with PTSD to Military Sexual Trauma	Participants recruited via advertisements and in therapy groups, staff meetings, & Veterans’ Centres	CAPS	12 weeks	12 x individual sessions of CPT (n = 72)	12 individual PCT (n = 57)	PCL, QIDS	6 months
Tylee et al. (2017) USA	30 male veterans (OEF/OIF)	Veterans’ groups & mental health services in San Diego County, California	PSS-I, PCL-M	1-3 weeks	3 x 120 min Reconsolidation of Traumatic Memories (NLP) (n = 15)	Wait list (n = 15)	None	12 months

Table 2. Meta-analytic results.

Comparison
Intervention vs. Waitlist/usual care	PTSD symptoms post-treatment	PTSD symptoms follow-up (less than 6 months)	PTSD symptoms follow-up (6-12 months)	Drop out rates	GRADE Rating
CBT-TF vs. waitlist/usual care	10 studies N=524	4 studies N=297	1 study N=42	Leaving the study early favoured the CBT-TF/Exposure arm (k=10; n=478; RR (M-H fixed), CI 1.78 1.06 to 3.00)	Low
	SMD (95% CI): -1.22 (-1.78, -0.66)	SMD (95% CI): -1.98 (-3.52,-0.44)	SMD (95% CI): -0.21 (-0.90, 0.48)
	Foa (2018), Forbes (2012), Gamito (2010), Gray (2017), Keane (1989), McLay (2011), Monson (2006), Peniston (1991), Reger (2016),Tylee (2017)	Foa (2018), Forbes (2012), Monson (2006), Peniston (1991)	Keane (1989)
Prolonged Exposure vs. Waitlist	2 studies N=228	1 study N=149	No data available	Leaving the study early favoured the PE arm (k=1; n=149; RR (M-H fixed), CI 23.48 1.47 to 374.96)	Low
	SMD (95% CI): -0.78 (-1.07, -0.49)	SMD (95% CI): -0.46 (-0.83, -0.10)
	Foa (2018), Reger (2016)	Foa (2018)
Cognitive Processing Therapy vs. waitlist/TAU	2 studies N=119	2 studies N=119	No data available	Leaving the study early favoured the CPT arm (k=2; n=119; (RR H-M, Fixed); CI 1.18 (0.55 to 2.51)	Very Low
	SMD (95% CI): -0.76 (-1.48, -0.03)	SMD (95% CI): -1.95 (-5.23, 1.33)
	Forbes (2012), Monson (2006)	Forbes (2012), Monson (2006)
Virtual Reality Exposure vs. Waitlist	3 studies N=104	No data available	No data available	Leaving the study early favoured the waitlist arm (k=3; n=30; (RR H-M, Fixed); CI 0.69 0.09 to 5.13)	Very Low
	SMD (95% CI): -0.43 (-0.83, -0.03)
	Gamito (2010), McLay (2011)
Group CBT-TF vs. waitlist/usual care/minimal contact	1 study N=86	No data available	No date available	Leaving the study early favoured the TFCBT arm (k=1; n=86; RR (M-H fixed); CI 1.64 (0.71 to 3.76)	Very Low
	SMD (95% CI): -1.28 (-1.74, -0.81)
	Castillo (2016)
Reconsolidation of Traumatic Memories (RTM) vs. Waitlist	2 studies N=96	No data available	No data available	Leaving the study early favoured the waitlist arm (k=2; n=104, (RR H-M, Fixed); CI 0.24 (0.03 to 2.13)	Very Low
	SMD (95% CI): -2.66 (-3.95, -1.37)
	Gray (2017), Tylee (2017)
Relaxation Training vs. waitlist/usual care	1 study N=25	No data available	No data available	There was no difference between the	Very Low
	SMD (95% CI): 0.33 (-0.46, 1.12)
	Carlson (1998)			arms on drop out (k=1; n= 25; RR (M-H fixed), CI 0.92 0.06 to 13.18)
EMDR vs. waitlist/usual care	4 studies N=92	No data available	No date available	There was no difference between the interventions on leaving the study early (k=4; n=118; RR (H-M, Fixed); CI 1.00 (0.53 to 1.90)	Very Low
	SMD (95% CI): -0.83 (-1.75, 0.10)
	Ahmadi (2015), Carlson (1998), Devilly (1998), Jensen (1994)
Intervention vs. Active Intervention	PTSD symptoms post-treatment	PTSD symptoms follow-up (less than 6 months)	PTSD symptoms follow-up (6-12 months)
Group CPT-TF vs. Individual CPT-TF	1 study N=268	1 study N=268	No data available	No data available	Low
	SMD (95% CI): 0.35 (0.11, 0.59)	SMD (95% CI): 0.17 (-0.07, 0.41)
	Resick (2017)
CBT-TF/Exposure therapy vs. Present Centred Therapy	4 studies N=612	2 studies N=370	No data available	Leaving the study early favoured the TFCBT/Exposure Therapy than PCT (k=4; n=633; RR (M-H fixed); CI 1.49 1.10 to 2.02)	Low
	SMD (95% CI): -0.50 (-0.91, -0.08)	SMD (95% CI): -0.23 [-0.43,-0.02]
	Foa (2018), Rauch (2015), Schnurr (2007), Suris (2013)	Schnurr (2007), Suris (2013)
Group CBT-TF vs. Group Present Centred Therapy	2 studies N=443	1 study N=108	1 study N=108	No data available	Very Low
	SMD (95% CI): -0.94 (-2.56, 0.69)	SMD (95% CI): -1.69 (-2.13, -1.25)	SMD (95% CI): -1.10 (-1.51,-0.70)
	Resick (2015), Schnurr (2003)	Resick (2015)	Resick (2015)
Couples non-CBT-TF versus couples psychoeducation	1 study N=43	1 study N-41	No data available	There was no difference between the interventions on leaving the study early (K=1; n=57; (RR H-M, Fixed); CI 0.97 (0.39 to 2.40)	Very Low
	SMD (95% CI): -1.37 (-2.04, -0.70)	SMD (95% CI): -7.01 (-8.72,-5.30)
	Sautter (2015)	Sautter (2015)
EMDR vs. Relaxation Training	1 study N=22	No data available	No data available	Leaving the study early favoured the EMDR arm (K=1; n=23; (RR H-M, Fixed); CI 1.33 (0.07 to 24.32)	Very Low
	SMD (95% CI): -0.46 (-1.31, 0.40)
	Carlson (1998), Suris (2013)
EMDR vs. REM-Desensitization	1 study N=21	No data available	No date available	Leaving the study early favoured the REM-D arm (k=1; n=32; (RR H-M Fixed); CI 0.83 (0.32 to 2.18)	Very Low
	SMD (95% CI): 0.06 (-0.80, 0.91)
	Ahmadi (2015)
Virtual Reality Exposure vs. Present Centred Therapy	1 study N=9	No data available	No data available	Leaving the study early favoured PCT arm (k=1; n=11; (RR H-M, Fixed); CI 0.83 (0.07 to 10.20)	Very Low
	SMD (95% CI): -0.51 (-1.86, 0.84)
	Ready (2010)
Virtual Reality Exposure vs. Control Exposure	2 study N=147	1 study N=52	1 study N=42	Leaving the study early favoured VRE arm (k=2; n=81; (RR H-R, Fixed) 13.30 (0.78, 225.31)	Low
	SMD (95% CI): 0.01 (-0.68, 0.71)	SMD (955 CI): 0.62 (0.06, 1.18]	SMD (95% CI): 0.53 (-0.10, 1.15)
	McLay (2017), Reger (2016)	Reger (2016)	Reger (2016)

Figure 2. CBT-trauma focused/exposure therapy vs. waitlist/usual care.

Figure 3. Prolonged exposure vs waitlist.

Figure 4. Cognitive processing therapy vs waitlist/TAU.

Figure 5. Trauma-focused CBT/exposure therapy vs present centred therapy.

Figure 6. Group trauma-focused CBT vs group present centred therapy.

Figure 7. Virtual reality exposure therapy vs waitlist.

Figure 8. Reconsolidation of traumatic memories vs waitlist/TAU.

Figure 9. EMDR vs waitlist/TAU.

Figure 10. Virtual reality exposure/control exposure.

Ahmadi, K., Hazrati, M., Ahmadizadeh, M., & Noohi, S. (2015). REM desensitization as a new therapeutic method for post-traumatic stress disorder: A randomized controlled trial. Acta Medica Indonesiana, 47(2), 1–17. PMID: 26260553.

 Web of Science ®Google Scholar

Carlson, J., Chemtob, C. M., Rusnak, K., Hedlund, N. L., & Muraoka, M. Y. (1998). Eye movement desensitization and reprocessing (EDMR) treatment for combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 11(1), 3–32.

 PubMed Web of Science ®Google Scholar

Castillo, D. T., Chee, C. L., Nason, E., Keller, J., C’de Baca, J., Qualls, C., & Keane, T. M. (2016). Group-delivered cognitive/exposure therapy for PTSD in women veterans: A randomized controlled trial. Psychological Trauma: Theory, Research, Practice and Policy, 8(3), 404–412.

 PubMed Web of Science ®Google Scholar

Devilly, G., Spence, S., & Rapee, R. (1998). Statistical and reliable change with eye movement desensitization and reprocessing: Treating trauma within a veteran population. Behavior Therapy, 29, 435–455.

 Web of Science ®Google Scholar

Foa, E., McLean, C. P., Zang, Y., Rosenfield, D., Yadin, E., Yarvis, J. S., & Peterson, A. L. (2018). Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-centered therapy on PTSD symptom severity in military personnel: A randomized clinical trial. JAMA, 319, 354–364.

 PubMed Web of Science ®Google Scholar

Forbes, D., Lloyd, D., Nixon, R. D. V., Elliott, P., Varker, T., Perry, D., … Creamer, M. (2012). A multisite randomized controlled effectiveness trial of cognitive processing therapy for military-related posttraumatic stress disorder. Journal of Anxiety Disorders, 26(3), 442–452.

 PubMed Web of Science ®Google Scholar

Gamito, P., Oliveira, J., Rosa, P., Morais, D., Duarte, N., Oliveira, S., & Saraiva, T. (2010). PTSD elderly war veterans: A clinical controlled pilot study. Cyberpsychology, Behavior and Social Networking, 13(1), 43–48. PMID: 20528292.

 PubMed Web of Science ®Google Scholar

Gray, R., Budden-Potts, D., & Bourke, F. (2017). Reconsolidation of traumatic memories for PTSD: A randomized controlled trial of 74 male veterans. Psychotherapy Research, 1–19. doi:10.1080/10503307.2017

 Web of Science ®Google Scholar

Jensen, J. (1994). An investigation of eye movement desensitisation and reprocessing (EMD/R) as a treatment for posttraumatic stress disorder (PTSD) symptoms of Vietnam combat veterans. Behavior Therapy, 25, 311–325.

 Web of Science ®Google Scholar

Keane, T., Fairbank, J. A., Caddell, J. M., & Zimering, R. T. (1989). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20(2), 245–260.

 Web of Science ®Google Scholar

McLay, R., Wood, D. P., Webb-Murphy, J. A., Spira, J. L., Wiederhold, M. D., Pyne, J. M., & Wiederhold, B. K. (2011). A randomized, controlled trial of virtual reality-graded exposure therapy for post-traumatic stress disorder in active duty service members with combat-related post-traumatic stress disorder. Cyberpsychology, Behavior and Social Networking, 14, 223–229.

 PubMed Web of Science ®Google Scholar

McLay, R., Baird, A., Webb-Murphy, J., Deal, W., Tran, L., Anson, H., … Johnston, S. (2017). A randomized, head-to-head study of virtual reality exposure therapy for posttraumatic stress disorder. Cyberpsychology, Behavior and Social Networking, 20, 218–224.

 PubMed Web of Science ®Google Scholar

Monson, C., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S. P. (2006). Cognitive processing therapy for veterans with military related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74, 898–907.

 PubMed Web of Science ®Google Scholar

Peniston, E. G., & Kulkosky, P. J. (1991). Alpha-theta brainwave neurofeedback for Vietnam veterans with combat-related post-traumatic stress disorder. Medical Psychotherapy, 4(1), 47–60.

 Google Scholar

Rauch, S., King, A. P., Abelson, J., Tuerk, P. W., Smith, E., Rothbaum, B. O., … Liberzon, I. (2015). Biological and symptom changes in posttraumatic stress disorder treatment: A randomized clinical trial. Depression and Anxiety, 32, 204–212.

 PubMed Web of Science ®Google Scholar

Ready, D. J., Gerardi, R. J., Backscheider, A. G., Mascaro, N., & Rothbaum, B. O. (2010). Comparing virtual reality exposure therapy to present centred therapy with 11 US Vietnam veterans with PTSD. Cyberpsychology, Behavior and Social Networking, 13(1), 49–54. PMID: 20528293.

 Web of Science ®Google Scholar

Reger, G., Koenen-Woods, P., Zetocha, K., Smolenski, D. J., Holloway, K. M., Rothbaum, B. O., & Gahm, G. A. (2016). Randomized controlled trial of prolonged exposure using imaginal exposure vs. virtual reality exposure in active duty soldiers with deployment-related posttraumatic stress disorder (PTSD). Journal of Consulting and Clinical Psychology, 84, 946–959.

 PubMed Web of Science ®Google Scholar

Resick, P. A., Wachen, J. S., Mintz, J., Young-McCaughan, S., Roache, J. D., Borah, A. M., & Peterson, A. L. (2015). A randomized clinical trial of group cognitive processing therapy compared with group present-centered therapy for PTSD among active duty military personnel. Journal of Consulting and Clinical Psychology, 83, 1058–1068. Epub 2015 May 4.

 PubMed Web of Science ®Google Scholar

Resick, P. A., Wachen, J. S., Dondanville, K. A., Pruiksma, K. E., Yarvis, J. S., Peterson, A. L., … Young-McCaughan, S. (2017). Effect of group vs individual cognitive processing therapy in active-duty military seeking treatment for posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry, 74(1), 28–36.

 PubMed Web of Science ®Google Scholar

Sautter, F. J., Glynn, S. M., Cretu, J. B., Senturk, D., & Vaught, A. S. (2015). Efficacy of structured approach therapy in reducing PTSD in returning veterans: A randomized clinical trial. Psychological Services, 12(3), 199–212.

 Web of Science ®Google Scholar

Schnurr, P., Friedman, M. J., Foy, D. W., Shea, M. T., Hsieh, F. Y., Lavori, P. W., & Bernardy, N. C. (2003). Randomized trial of trauma-focused group therapy for posttraumatic stress disorder. Archives of General Psychiatry, 60, 481–489.

 PubMed Web of Science ®Google Scholar

Schnurr, P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M. T., Chow, B. K., … Bernardy, N. (2007). Cognitive behavioural therapy for posttraumatic stress disorder in women. JAMA, 28, 820–830.

 Web of Science ®Google Scholar

Suris, A., Link-Malcolm, J., Chard, K., Ahn, C., & North, C. (2013). A randomized clinical trial of cognitive processing therapy for veterans with PTSD related to military sexual trauma. Journal of Traumatic Stress, 26, 28–37.

 PubMed Web of Science ®Google Scholar

Tylee, D. S., Gray, R., Glatt, S. J., & Bourke, F. (2017). Evaluation of the reconsolidation of traumatic memories protocol for the treatment of PTSD: A randomized, wait-list-controlled trial. Journal of Military, Veteran and Family Health, 3(1), 21–33.

 Google Scholar