Early psychological intervention following recent trauma: A systematic review and meta-analysis

Figures & data

Table 1. Description of included studies.

Source and Country	Intervention and Conditions	Mean Number of Sessions Attended	Population	Time Since Trauma at Start of Intervention	Severity Criterion	Traumatic Stress Outcome Measures	Randomized (n): Completers (n)	Follow-up Period	Significant Differences
Als, Nadel, Cooper, Vickers, and Garralda, 2015 UK	Telephone supported psychoeducation vs. TAU	Intervention was self-directed	Parents of children admitted to a paediatric intensive care unit (ICU)	Within 7 days of discharge.	None	IES	31: 23	3–6 post discharge	Neutral
Andre et al., 1997 France	Up to 6 sessions of CBT vs. usual care	2.35	Assaulted bus drivers recruited via an urban bus company	At least 14 days	None	IES	132:	6 months	Neutral
Ben-Zion et al., 2018 Israel	Daily computerized neurobehavioral training (CNT) for 30 days vs a computerized games control vs a reading task control	Intervention was computerized. Usage was not reported	Physical injury from civilian trauma recruited from general hospital	At least 7 days	Probable PTSD diagnosis	CAPS, CAPS-5	97: 52 were identified as completers.	3 and 6 months post trauma	CNT was reported to be better than the combined controls but analysis was only conducted on those completing intervention.
Biggs et al., 2016 USA	Four 2-hour interactive group based sessions based on Psychological First Aid vs. assessment only	2.22	Military mortuary attendants returning from deployment in the Middle East	One month	None	PCL	126: 125	2, 3, 4, 7, and 10 months post deployment	Neutral
Bisson, Shepherd, Joy, Probert, and Newcombe, 2004 UK	Four 60 min. sessions of exposure based CBT vs. standard care	3.30	Physical injury from civilian trauma recruited from a hospital accident and emergency unit	5–10 weeks	Acute psychological distress	CAPS, IES	152: 124 completed to 3 months	3 and 13 months post trauma	CBT-T better than standard care at 13 months only
Borghini et al., 2014 Switzerland	Three 60 minute parenting sessions over 6 months vs. standard care	Not reported	Mothers of infants born prematurely recruited through a neonatal intensive care unit	Within one week	None	Perinatal PTSD Questionnaire (PPQ)	60: 55	42 weeks post conception and 4 and 12 months corrected infant birth.	Neutral
Brom, Kleber, and Hofman, 1993 Netherlands	Up to six sessions of individual preventative counselling vs. monitoring group	Not reported	Outpatient victims of MVA recruited through police records.	Not reported	None	IES, TSI	738 randomized, 151 agreed to enter study: 121 completed	3 months post treatment	Neutral
Brunet, Des Groseilliers, Cordova, and Ruzek, 2013 Canada	Two sessions of dyadic CBT vs. assessment only	Not reported	Physical injury from civilian trauma recruited from emergency departments of public hospitals	Mean 26 days	None	IES-R, CAPS	83 randomized: 66 completed as per protocol	Post treatment,	Dyadic CBT better than assessment only
Bryant, Harvey, Dang, Sackville, and Basten, 1998 Australia	Five 90 min. weekly sessions of exposure based CBT vs supportive counselling	Not reported	Outpatients recruited from a hospital PTSD clinic following MVA or industrial accident	Mean 9.9 days (CBT); 10.3 days SC	Acute Stress Disorder	IES, CIDI PTSD module	Unclear: 24 completed	6 months and 4 years post trauma	CBT-T better than SC
Bryant, Sackville, Dang, Moulds, and Guthrie, 1999 Australia	Five 90 min. weekly sessions of prolonged exposure or prolonged exposure plus anxiety management vs. supportive counselling	Not reported	Outpatients recruited from a hospital PTSD clinic following MVA or non- sexual assault	Mean 10.3 days (exposure plus anx mgmt), 10.0 days (PE), 10.6 days (SC)	Acute Stress Disorder	CAPS, IES	56: 45 completed	6 months and 4 years post trauma	CBT-T and CBT-T plus AM better than SC
Bryant, Moulds, Guthrie, and Nixon, 2003 Australia	Five 90 min. weekly sessions of exposure based CBT vs. supportive counselling	Not reported	Outpatients with mild traumatic brain injury from MVA or non-sexual assault recruited from a hospital PTSD clinic	2 weeks	Acute Stress Disorder	CAPS, IES	24: 24 completed	Post treatment and 6 months post trauma	CBT-T better than SC
Bryant, Moulds, Guthrie, and Nixon, 2005 Australia	Six 90 min. sessions of exposure based CBT or CBT plus hypnosis vs. supportive counselling	Not reported	Outpatients following MVA or non-sexual assault recruited from a hospital PTSD clinic	Mean 15.8 days (CBT); 13.5 days (CBT-hypnosis); 14.0 days (SC)	Acute Stress Disorder	CAPS, IES	87: 69 completed	Post treatment and 6 months and 3 years post trauma	CBT-T and CBT-T plus hypnosis better than SC.
Bryant et al., 2008 Australia	Five 90 min sessions of exposure therapy or cognitive restructuring vs. waiting list	Not reported	Outpatient victims of civilian trauma recruited from a hospital traumatic stress service	Mean 22.8 days	Acute Stress Disorder	CAPS, IES	69 completed	Post treatment and 6 months post trauma	Exposure therapy and Cognitive restructuring better than WL. ET better than CR
Bugg, Turpin, Mason, and Scholes, 2009 UK	One face to face and two telephone sessions with a trauma related writing task and information intervention vs information only	Not reported	Outpatient victims of MVA, occupational injury or assault recruited from a hospital accident and emergency clinic	5–6 weeks	Acute Stress Disorder	PDS	148 randomized: 67 available to initial follow-up	3 and 6 months post trauma	Neutral
Cernvall, Carlbring, Ljungman, Ljungman, and von Essen, 2015 Sweden	Ten weeks of therapist supported internet and CBT based guided self-help vs. assessment only	Not reported	Parents of children with cancer recruited from paediatric oncology centres	Not reported	PTSD symptom positive	PCL-C	58: 37	Post-treatment	Guided self-help was better than assessment only
Cox et al., 2018 USA	Six 30 minute telephone and web CBT based sessions of coping skill training (CST) vs. education only	2.7 for CST; 0.8 for education only	Patients admitted to an ICU and receiving > 48 hours of mechanical ventilation	2 weeks post discharge	None	IES-R	175: 136	3 and 6 months post baseline	Neutral
Curtis et al., 2016 USA	Provision of an inpatient patient/family communication facilitator vs. usual care	9.4 contacts per family	Family members of patients in an ICU	Randomization occurred following admission	None	PCL	268: 133	3 and 6 months following death or discharge of the patient	Neutral for PTSD
Echeburua, de Corral, Sarasua, and Zubizarreta, 1996 Spain	Five 60 min. session of exposure based CBT vs. relaxation	Not reported	Female victims of rape or sexual assault recruited from a psychological counselling centre for women	1.4 months	Acute PTSD	Scale of Severity of PTSD Symptoms,	20: 20 completed	Post treatment, 3, 6 and 12 months post treatment	CBT-T better than relaxation at 12 month follow-up only
Ehlers et al., 2003 UK	Twelve plus three 90 min. sessions of trauma focused CBT or self-help booklet vs. waiting list	11.4	Outpatient victims of MVA recruited from local accident and emergency departments	4 months	Acute and chronic PTSD	CAPS, PDS	85: 80 completed 12 participants met criteria for acute PTSD and were included in this review. All 12 completed	3 and 9 months post baseline	CBT-T better than self help booklet and WL
Foa, Zoellner, and Feeny, 2006 USA	Four 2 hour sessions of exposure based CBT or supportive counselling vs. continuous assessment	Not reported	Female victims of sexual and non-sexual assault recruited via emergency rooms, police officers, medical professionals, local victim assistance agencies, and media advertisements	20.5 days to assessment	PTSD symptom criteria	SCID-PTSD, PSSI	90: 66 completed	Post treatment, 2, 3, 6, 9 and 12 months post treatment	Neutral
Freedman, n.d. Israel; Freedman, Dayan, Kimelman, Weissman, and Eitan 2015	Five sessions of virtual reality and CBT based vs. waiting list	Not reported	Motor vehicle accident (MVA) recruited via an emergency room	14 days to assessment	PTSD symptom positive	CAPS-5	14: 14	Post treatment, 6 and 12 months	Neutral
Freedman, in press Israel	Five sessions of telephone based CBT vs. waiting list	Not reported	Physical injury from civilian trauma recruited via a hospital emergency department	16 days to assessment	Diagnosis for acute PTSD apart from the duration criteria	CAPS	139: number completing not clear	3 and 7 months post trauma	Neutral
Freyth, Elsesser, Lohrmann, and Sartory, 2010 Germany	Three 90 minute sessions of exposure based CBT vs supportive counselling	Not reported	Various trauma exposed outpatients recruited from a university psychology department outpatient treatment centre	20.5 days to assessment	Acute Stress Disorder	IES-R	46: 40	Post treatment and 3 months post treatment	Neutral
Gamble et al., 2005 Australia	1 session of face to face counselling and 1 session of telephone counselling lasting up to 60 mins vs treatment as usual	Not reported	Mothers recruited via an ante-natal clinic following traumatic birth	Within 72 hours	None	MINI-PTSD	103: 102 completed initial follow-up, 103 completed 3 month follow-up	4–6 weeks and 3 months post-partum	Intervention better than treatment as usual at 3 months only
Gamble, 2010 Australia	1 session of face to face counselling and 1 session of telephone counselling vs parenting support	Not reported	Mothers recruited via an ante-natal clinic following traumatic birth	72 hours	None	PDS	262: 219	6 weeks, 6 and 12 months post-partum	Neutral
Gidron et al., 2001 Israel	Two sessions of Memory structuring intervention vs. supportive listening	Not reported	Outpatient victims of an MVA recruited via an emergency department.	24 hours	Heart rate greater than 95 beats per minute in emergency room	PDS	Number randomized unclear: 17 completed	3–4 months post trauma	Memory structuring intervention better than supportive listening
Gidron et al., 2007 Israel	Two sessions of Memory structuring intervention vs. supportive listening	Not reported	Outpatient victims of an MVA recruited via a university medical centre.	Within 48 hours	Heart rate greater than 95 beats per minute in emergency room.	PDS	Number randomized unclear: 34 completed	3 months post trauma	Neutral
Holmes et al., 2007 Australia	Six sessions of Interpersonal Counselling vs. assessment only	3.53	Major physical trauma recruited via a hospital trauma centre	Screening occurred at 2 weeks.	None	PCL	90: 84 27 of 51 completed intervention	3 and 6 months post treatment	Neutral
Irvine et al., 2011 Canada	Eight sessions of telephone based CBT vs. treatment as usual	Not reported	Patients receiving implantable cardioverter defibrillator transplant recruited via a hospital	Unclear – normally soon after discharge	None	IES-R	193: 171 (a further 8 participants died)	6 and 12 months post baseline	Intervention was better than treatment as usual at 6 and 12 months for women and at 12 months for men.
Jarero, Artigas, and Luber, 2011 Mexico	One 130 minute session of EMDR vs delayed treatment	1	Earthquake survivors recruited via a private company	16 days	Screened positive for PTSD	IES	18: 18	Post treatment	EMDR was better than delayed treatment
Jarero, Uribe, Artigas, and Givaudan, 2015 Mexico	Two 60 minute sessions of EMDR vs delayed treatment	Unclear	Exposure to a fatal factory explosion	25 days	Screened positive for PTSD	SPRINT	Number randomized unclear: 25 completed	Post treatment	EMDR was better than delayed treatment
Jensen et al., 2016 Denmark	Three sessions of CBT based nurse led psychological intervention vs. usual care	1.92; 34 intervention patients died during the intervention period	Patients admitted to ICU requiring mechanical ventilation	Within one month of discharge	None	Harvard Trauma Questionnaire	386: 235	3 and 12 months post discharge	Neutral
Jones et al., 2010 Denmark, Italy, Norway, Portugal, Sweden, UK	Feedback from an (ICU) admissions diary vs. delayed feedback	All randomized patients attended their feedback session	Admission to ICU ≥ 72 hours	Feedback was provided at 1 month post discharge	None	PDS, PTSS-14	352: 322	3 months post discharge	Diary feedback was better than delayed feedback
Kazak et al., 2005 USA	Three 45 min sessions of adapted CBT and family therapy intervention vs treatment as usual	Primary care givers: 2.22 Secondary care givers 2.33	38 caregivers and parents of children newly diagnosed with cancer recruited from a children’s hospital oncology service.	Median 6 days, range 0–10 days	None	IES-R	38: 31 completed available to follow-up	2 months post treatment	Neutral
Lindwall et al., 2014* USA	Three sessions of parent and child targeted psychoeducation, massage, relaxation and guided imagery vs. usual care	Not reported	Parents of children undergoing stem cell or bone marrow transplantation recruited via paediatric stem cell transplantation centres	Unclear. Recruitment occurred prior to transplantation.	None	IES-R	113:	24 weeks post admission	Neutral
Marchand et al., 2006 Canada	Two 1 hour sessions of adapted critical incident stress debriefing vs a no intervention control group	Not reported	Outpatient victims of armed robbery recruited via a convenience store chain.	11.21 days	Meet criterion A1 and A2 for PTSD	SCID, IES	75: 61 available at 1 month follow-up	1 and 3 months post baseline	Intervention better than adapted CISD initially only
Mouthaan et al., 2013 Netherlands	Self-guided CBT based internet intervention vs care as usual	Mean log-ins was 1.7. 77.5% logged in once or more.	Hospitalized severe injury patients recruited via a trauma centre	1 week post injury	None	CAPS, IES-R	300: 231 completed 1 month assessment, 189 completed 3 months assessment	1, 3, 12 and 12 months post injury	Neutral
Nixon, 2012 Australia	Six 90 minute sessions of cognitive processing therapy vs. supportive counselling	Not reported	Mainly self-referring assault victims recruited via advertising, victims support agencies, police, and via general media alerts	Screening occurred within 4 weeks	ASD	CAPS, PDS	30: 21	Post-treatment and 6 months	Neutral
Nixon et al., 2016 Australia	Six 90 minute sessions of cognitive processing therapy vs. supportive counselling	3.5	Rape and sexual assault survivors recruited from a rape and sexual assault crisis centre	Screening occurred within 4 weeks	ASD	CAPS, PCL-S	49: 32	Post-treatment, 3, 6 and 12 months	Neutral
O’Donnell et al., 2012 Australia	Up to 10 sessions of CBT based stepped care vs. usual care	6.3	MVA and assault recruited from trauma units	Final screening and assessment occurred after 4 weeks	Clinically significant symptoms of PTSD, depression or anxiety	CAPS	46: 42	6 and 12 months post baseline	CBT was better than usual care
O’Donnell, Lau, Howard, and Alkemade et al.,n.d. Australia	Up to 10 sessions of telephone CBT vs. usual care.	6.2	Trauma unit patients of MVA, accident or assault recruited from trauma services	Final screening and assessment occurred after 4 weeks	Clinically significant mental health problems	CAPS	61: 54	6 and 12 months post injury	Neutral
Öst, Paunovic, and Gillow, n.d. Sweden	Sixteen 60 min. sessions of exposure based CBT vs. waiting list	8.7	Outpatient victims of violent crime recruited through local psychiatric units and the police	6.8 weeks	Acute PTSD	CAPS, IES-R	43: 41	Post treatment only	CBT-T better than wait list
Rothbaum et al., 2012 USA	Three 60 min. sessions of modified prolonged exposure vs. assessment only	2.61	Trauma exposed individuals admitted to a hospital emergency department	72 hours	None	PSS-I, PDS	137: 102	4 and 12 weeks post enrolment	Mixed -CBT-T was better than waiting list for PSS-I scores but not PDS
Ryding, Wijma, and Wijma, 1998 Sweden	Two group sessions of counselling and education vs treatment as usual.	Not reported	Women following emergency caesarean section recruited via a hospital obstetrics and gynaecology department	Not clearly stated, a few days after giving birth	None	IES	106: 100 completed	6 months post-partum	Neutral
Ryding, Wiren, Johansson, Ceder, and Dahlstrom, 2004 Sweden	Two group sessions of counselling and education vs treatment as usual.	Not reported	Women following emergency caesarean section recruited via a hospital obstetrics and gynaecology department	2 months	None	IES	162: 147 available at initial follow-up	6 months post-partum	Neutral
Shalev et al., 2012** Israel	Twelve 90 minute sessions of prolonged exposure (PE) vs cognitive therapy (CT) vs waiting list	Not reported	Mainly MVA and acts of terrorism survivors recruited via hospitals emergency services	Recruitment occurred at a mean of 19.8 day after trauma	PTSD or partial PTSD	CAPS, PSS-R	196: 168 available at initial follow-up	4 and 9 months post trauma	PE and CT were better than wait list. There was no difference between PE and CT
Shapiro and Laub, 2015 Israel	Two 90 minute sessions of EMDR vs delayed treatment	Not reported	Survivors of a missile attack recruited through the community	The study began 6 weeks after the incident	Screened positive for PTSD and/or depression	IES-R	17: 17	Post-treatment	EMDR better than delayed treatment
Shapiro, Laub, and Rosenblat, 2018 Israel	Three 90 minute sessions of EMDR vs delayed treatment	Not reported	Treatment seeking individuals exposured to a rocket attack	Recruitment began 2–3 months after the incident.	Individuals presenting seeking treatment	PCL-5	25: 24	Post-treatment	EMDR better than delayed treatment
Shaw et al., 2013 USA	Six 50 minute sessions of CBT-T vs. usual care	Not reported	Mothers of premature infants recruited from neonatal intensive care units	Baseline assessment was at 1–2 weeks	Screened positive for ASD, depression, anxiety or acute stress	DTS	105: 98	Post-treatment	CBT-T better than usual care
Sijbrandij et al., 2007 Netherlands	Four 2 hour weekly sessions of exposure based CBT vs. waiting list	3.30	Outpatient victims of civilian traumatic events referred via the emergency room and trauma unit of an academic medical centre, and by victim support workers, general practitioners, and company doctors	40 days	Acute PTSD, (some participants did not meet the onset criterion)	SI-PTSD	143: 117 completed	1 week and 4 months post treatment	Neutral
Skogstad, Hem, Sandvik, and Ekeberg, 2015 Norway	Up to 6 60 minute sessions of nurse led CBT vs. usual care	Not reported	Outpatient victims of trauma recruited from a hospital a trauma referral centre	Before 3 months	Screening positively for PTSD on the IES	IES	145: 85	3 and 12 months post injury	Neutral
Taghizadeh et al., 2008 Iran	Up to 6 weeks of 60 minutes sessions of counselling vs. usual care	Not reported	Traumatic birth recruited via a hospital	Within 72 hours	None	IES	300: number of completers not reported	4–6 weeks and 3 months post-partum	Neutral at 4–6 weeks, counselling better than usual care at 3 months
van Emmerik, Kamphuis, and Emmelkamp, 2008 Netherlands	Five 90 minute sessions of exposure based CBT, or a writing intervention vs. waiting list condition.	Not reported	Outpatients following civilian trauma referred to a university clinical psychology department	Mean of 119.40 days	ASD, acute PTSD Or chronic PTSD	IES	125: 85 completed 66 eligible for this review: 47 completed	No consistent point of long-term follow-up	CBT-T and writing intervention better than wait list
Wang et al., 2015 China	Eight 40 minutes sessions of group based creative arts using drawing and creative writing vs waiting list	Not reported	MVA victims recruited via a hospital emergency department	Not clearly stated. Recruitment occurred at 96 hours post injury	None	CAPS, IES-R	52: 46	2, 6 and 12 months post enrolment	Neutral
Wagner, Zatzick, Ghesquiere, and Jurkovich, 2007 USA	Up to six 90 min. sessions of behavioural activation and treatment as usual vs. treatment as usual.	5.75	Inpatients following civilian trauma recruited from a medical ward in a trauma centre	> 4 weeks	Acute PTSD	PCL	8: 8 completed	3 months post-trauma	Neutral
Wijesinghe et al., 2015 Sri Lanka	Psychoeducatione session + one session CBT vs. psychoeducation only vs. assessment only	Not reported	Snakebite victims recruited via a hospital	At discharge from hospital after antivenom treatment	None	PSS-SR	225: 202	6 months post discharge	Neutral
Wu, Li, and Cho, 2014 Hong Kong	Four 90 minute sessions of CBT-T vs. a self-help booklet	2.45	MVA victims recruited through the emergency department of a district medical centre	Baseline assessment at 1 month	Traumatic stress symptoms at 1 month	IES-R	60: 37	3 and 6 months post MVA	Neutral
Zatzick et al., 2001 USA	Collaborative care intervention, including assignment to trauma support specialist vs usual care	92 minutes of clinical contact	Physically injured hospitalized MVA & assault victims recruited from a hospital trauma centre	Within 1 month	All hospitalized individuals	PCL	34: 26 completed	1 and 4 months post injury	Neutral
Zatzick et al., 2004 USA	Multifaceted collaborative care for PTSD and alcohol abuse vs usual care	10.7 hours of clinical contact	Physically injured hospitalized MVA & assault victims recruited from a hospital trauma centre	Not clearly stated but soon after admission	Significant symptoms of PTSD and/or depression	PCL	121: 106 retained at 1 month, 99 retained at 12 months	1, 3, 6 and 12 months post admission	Neutral
Zatzick et al., 2013 USA	Multifaceted collaborative care for PTSD, alcohol abuse and other high risk behaviours vs usual care	Median 13.2 hours of clinical contact	Physically injured hospitalized trauma survivors recruited from a hospital trauma centre	Not clearly stated but soon after discharge	Screening positively for PTSD at admission and discharge	CAPS, PCL	207: 164 retained at 3 months, 167 retained at 12 months	1, 3, 6, 9 and 12 months post admission	Collaborative care better than usual care
Zatzick et al., 2015 USA	Technology enhanced collaborative care for PTSD, alcohol abuse and other high risk behaviours vs usual care	Median 2.25 hours of clinical contact	Physically injured hospitalized trauma survivors recruited from a hospital trauma centre.	Not clearly stated but began during admission	Screening positively for PTSD	PCL	121: 108 retained at 1 month, 105 retained at 6 months	1, 3, and 6 months post admission	Neutral

*This study included an additional arm where intervention was offered only to the child. Data from this arm are not included

**This study included two additional arms evaluating Escitalopram and placebo medication. Data for these arms are not included in this table.

Figure 1. Flow diagram of the systematic review.

Table 2. Summary of meta-analysis of results for interventions.

Comparison	Follow-up (and contributing studies)	Trials (n)	Sample (n)	Relative Risk (95% CI)	Standardized Mean Difference (95% CI)	Grade Rating
Interventions within one month for all exposed to the trauma
Brief individual processing therapies vs usual care (PTSD severity)	Post treatment (Brom et al., 1993; Gamble et al., 2005; Marchand et al., 2006; Rothbaum et al., 2012) 3–6 months post trauma (Brom et al., 1993; Gamble et al., 2005; Marchand et al., 2006; Rothbaum et al., 2012)	4 4	465 466		0.04 (−0.34, 0.42) -0.07 (−0.25, 0.12)	Very low Very low
Brief individual processing therapies vs usual care (PTSD diagnosis)	Post treatment (Gamble et al., 2005; Marchand et al., 2006; Rothbaum et al., 2012) 3–6 months post trauma (Gamble et al., 2005; Marchand et al., 2006; Rothbaum et al., 2012)	3 3	262 251	1.10 (0.87, 1.40) 0.73 (0.44, 1.22)		Very low Very low
Brief dyadic therapy vs usual care (PTSD severity)	3–6 months post trauma (Brunet et al., 2013; Kazak et al., 2005)	2	103		−0.41 (−0.81, −0.02)*	Very low
Brief individual trauma processing therapy vs supportive listening	3–6 months post trauma (Gidron et al., 2001; Gidron et al., 2007)	2	51		−0.54 (−1.42, 0.34)	Very low
Interventions beginning within three months for individuals with traumatic stress symptoms
Trauma focused CBT vs waitlist (PTSD severity)	Post treatment (Bisson et al., 2004; Bryant et al., 2008; Ehlers et al., 2003; Foa et al., 2006; Öst et al., n.d.; Shalev et al., 2012; Shaw et al., 2013; Sijbrandij et al., 2007; van Emmerik et al., 2008) 3–6 months post trauma (Ehlers et al., 2003; Foa et al., 2006; Shalev et al., 2012; Shaw et al., 2013; Sijbrandij et al., 2007) 7–12 months post trauma (Bisson et al., 2004; Foa et al., 2006) 2 years post trauma (Shalev et al., 2012)	9 5 2 1	746 420 213 67		−0.63 (−0.93, −0.32)* -0.30 (−0.58, −0.02)* -0.25 (−0.52, 0.02) -0.03 (−0.45, 0.51)	Low Low Low Very low
Trauma focused CBT vs waitlist (PTSD diagnosis)	Post treatment (Bisson et al., 2004; Bryant et al., 2008; Ehlers et al., 2003; Foa et al., 2006; Öst et al., n.d.; Shalev et al., 2012; Sijbrandij et al., 2007; van Emmerik et al., 2008) 3–6 months post trauma (Ehlers et al., 2003; Foa et al., 2006; Shalev et al., 2012; Sijbrandij et al., 2007) 7–12 months post trauma (Bisson et al., 2004; Foa et al., 2006) 2+ years post trauma (Shalev et al., 2012)	8 4 2 1	671 309 158 67	0.67 (0.47, 0.96)* 0.61 (0.46, 0.82)* 0.73 (0.42, 1.28) 0.91 (0.44, 1.90)		Moderate Low Very low Very low
Cognitive therapy vs waitlist (PTSD severity)	Post treatment (Bryant et al., 2008; Shalev et al., 2012) 3–6 months post trauma (Shalev et al., 2012) 2 years post trauma (Shalev et al., 2012)	2 1 1	172 92 57		−0.68 (−1.00, −0.35)* -0.13 (−0.55, 0.30) 0.05 (−0.47, 0.57)	Low Very low Very low
Cognitive therapy vs waitlist (PTSD diagnosis)	Post treatment (Bryant et al., 2008; Shalev et al., 2012) 3–6 months post trauma (Shalev et al., 2012) 2+ years post trauma (Shalev et al., 2016)	2 1 1	172 133 57	0.66 (0.39, 1.12) 0.52 (0.30, 0.89)* 1.28 (0.63, 2.59)		Low Very low Very low
EMDR vs waitlist (PTSD severity)	Post treatment	4	84		−2.50 (−4.25, −0.75)*	Very low
Telephone-based CBT-T vs waitlist (PTSD severity)	Post treatment (Freedman, in press; O’Donnell et al., n.d.) 3–6 months post trauma (O’Donnell et al., n.d.)	2 1	191 61		0.06 (−0.22, 0.35) 0.28 (−0.22, 0.79)	Low Very low
Stepped collaborative care vs usual care (PTSD severity)	1-month post trauma (Zatzick et al., 2013; Zatzick et al., 2015) 3–6 months post trauma (O’Donnell et al., 2012; Zatzick et al., 2013; Zatzick et al., 2015) 7–12 months post trauma (O’Donnell et al., 2012; Zatzick et al., 2013)	2 3 2	328 370 238		−0.05 (−0.27, 0.17) -0.45 (−0.65, −0.24)* -0.61 (−1.41, 0.20)	Moderate Moderate Low
Stepped collaborative care vs usual care (PTSD diagnosis)	1-month post trauma (Zatzick et al., 2004) 3–6 months post trauma (O’Donnell et al., 2012; Zatzick et al., 2004) 7–12 months post trauma (O’Donnell et al., 2012; Zatzick et al., 2004)	1 2 2	106 144 122	0.85 (0.42, 1.69) 0.42 (0.14, 1.26) 0.55 (0.28, 1.09)		Very low Very low Very low
Trauma Focused CBT vs Supportive Counselling (PTSD severity)	Post treatment (Bryant et al., 1998; Bryant et al., 2005; Bryant et al., 1999; Bryant et al., 2003; Foa et al., 2006; Freyth et al., 2010; Nixon, 2012; Nixon et al., 2016) 3–6 months follow-up (Bryant et al., 1998; Bryant et al., 2005; Bryant et al., 1999; Bryant et al., 2003; Foa et al., 2006; Freyth et al., 2010; Nixon, 2012; Nixon et al., 2016) 7–12 months post trauma (Foa et al., 2006; Nixon et al., 2016) 2+ years post trauma (Bryant, Moulds, & Nixon, 2003)	8 8 2 2	331 314 106 94		−0.61 (−1.01, −0.22)* -0.58 (−0.87, −0.28)* -0.06 (−0.45, 0.32) -0.72 (−1.16, −0.28)*	Low Low Very low Very low
Trauma Focused CBT vs Supportive Counselling (PTSD diagnosis)	Post treatment (Bryant et al., 1998; Bryant et al., 2005; Bryant et al., 1999; Bryant et al., 2003; Foa et al., 2006; Nixon et al., 2016) 3–6 months follow-up (Bryant et al., 1998; Bryant et al., 2005; Bryant et al., 1999; Bryant et al., 2003; Foa et al., 2006) 2+ years post trauma (Bryant et al., 2003)	6 5 2	281 200 170	0.61 (0.36, 1.04) 0.37 (0.20, 0.67)* 0.68 (0.48, 0.96)*		Low Low Very low
Trauma Focused CBT vs self-help (PTSD severity)	Post treatment (Ehlers et al., 2003; Wu et al., 2014) 3–6 months follow-up (Ehlers et al., 2003; Wu et al., 2014)	2 2	47 63		−0.57 (−1.25, 0.11) -0.59 (−1.41, 0.22)	Very low Very low
Trauma Focused CBT vs Cognitive Therapy (PTSD severity)	Post treatment (Bryant et al., 2008; Shalev et al., 2012) 3–6 months post trauma (Bryant et al., 2008; Shalev et al., 2012) 2+ years post trauma (Shalev et al., 2016)	2 2 1	149 147 60		−0.19 (−0.52, 0.14) -0.25 (−0.58, 0.08) -0.02 (−0.53, 0.49)	Low Low Very low
Trauma Focused CBT vs Cognitive Therapy (PTSD diagnosis)	Post treatment (Bryant et al., 2008; Shalev et al., 2012) 3–6 months post trauma (Bryant et al., 2008; Shalev et al., 2012) 2+ years post trauma (Shalev et al., 2016)	2 2 1	163 163 60	0.70 (0.40, 1.22) 0.87 (0.38, 1.97) 0.60 (0.20, 1.78)		Low Low Very low
Interventions for individuals with stress disorder or post-traumatic stress disorder
Trauma Focused CBT vs Waitlist (PTSD severity)	Post treatment (Bryant et al., 2008; Ehlers et al., 2003; Öst et al., n.d.; Shalev et al., 2012; Sijbrandij et al., 2007; van Emmerik et al., 2008) 3–6 months post trauma (Ehlers et al., 2003; Shalev et al., 2012) 2 years + (Shalev et al., 2012)	6 2 1	387 121 67		−0.89 (−1.23, −0.56)* -0.84 (−2.49, 0.80) 0.03 (−0.45, 0.51)	Low Very low Very low
Trauma Focused CBT vs Waitlist (PTSD diagnosis)	Post treatment (Bryant et al., 2008; Ehlers et al., 2003; Öst et al., n.d.; Shalev et al., 2012; Sijbrandij et al., 2007; van Emmerik et al., 2008) 3–6 months post trauma (Ehlers et al., 2003; Shalev et al., 2012) 2 years + post trauma (Shalev et al., 2012)	6 2 1	410 168 67	0.54 (0.35, 0.82)* 0.59 (0.40, 0.87) 0.91 (0.44, 1.90)		Low Very low Very low
Cognitive therapy vs waitlist (PTSD severity)	Post treatment (Bryant et al., 2008; Shalev et al., 2012) 3–6 months post trauma (Shalev et al., 2012) 2 years post trauma (Shalev et al., 2012)	2 1 1	172 92 57		−0.68 (−1.00, −0.35)* -0.13 (−0.55, 0.30) 0.05 (−0.47, 0.57)	Low Very low Very low
Cognitive therapy vs waitlist (PTSD diagnosis)	Post treatment (Bryant et al., 2008; Shalev et al., 2012) 3–6 months post trauma (Shalev et al., 2012) 2+ years post trauma (Shalev et al., 2016)	2 1 1	172 133 57	0.66 (0.39, 1.12) 0.52 (0.30, 0.89)* 1.28 (0.63, 2.59)		Low Very low Very low
Trauma Focused CBT vs Supportive Counselling (PTSD severity)	Post treatment (Bryant et al., 1998; Bryant et al., 2005; Bryant et al., 1999; Bryant et al., 2003; Nixon, 2012; Nixon et al., 2016) 3–6 months post trauma (Bryant et al., 1998; Bryant et al., 2005; Bryant et al., 1999; Bryant et al., 2003; Nixon, 2012; Nixon et al., 2016) 7–12 months post trauma (Nixon et al., 2016) 2+ years post trauma (Bryant et al., 2003; Bryant et al., 2006)	6 6 1 2	231 217 46 94		−0.75 (−1.03, −0.47)* -0.74 (−1.03, −0.45)* -0.38 (−0.96, 0.21) -0.72 (−1.16, −0.28)*	Low Low Very low Very low
Trauma Focused CBT vs Supportive Counselling (PTSD diagnosis)	Post treatment (Bryant et al., 1998; Bryant et al., 2005; Bryant et al., 1999; Bryant et al., 2003; Nixon, 2012) 3–6 months post trauma (Bryant et al., 1998; Bryant et al., 2005; Bryant et al., 1999; Bryant et al., 2003) 3–4 years (Bryant et al., 2003; Bryant et al., 2006)	5 4 2	221 158 170	0.30 (0.17, 0.53)* 0.26 (0.16, 0.45)* 0.68 (0.48, 0.96)*		Low Low Very low
Trauma Focused CBT vs Cognitive Therapy (PTSD severity)	Post treatment (Bryant et al., 2008; Shalev et al., 2012) 3–6 months post trauma (Bryant et al., 2008; Shalev et al., 2012) 2+ years post trauma (Shalev et al., 2016)	2 2 1	149 147 60		−0.19 (−0.52, 0.14) -0.25 (−0.58, 0.08) -0.02 (−0.53, 0.49)	Low Low Very low
Trauma Focused CBT vs Cognitive Therapy (PTSD diagnosis)	Post treatment (Bryant et al., 2008; Shalev et al., 2012) 3–6 months post trauma (Bryant et al., 2008; Shalev et al., 2012) 2+ years post trauma (Shalev et al., 2016)	2 2 1	163 163 60	0.70 (0.40, 1.22) 0.87 (0.38, 1.97) 0.60 (0.20, 1.78)		Low Low Very low

Relative risk = of diagnosis of PTSD. 1 = same as control, < 1 = intervention better, > 1 = control better.

Standardized mean difference = of continuous PTSD symptom score. If SMD = 0 there is no difference between the intervention and the control. < 0 = intervention better, > 0 = control better.

*Statistically significant difference at p < 0.05 level.

Figure 2. Forest plot of PTSD severity, post treatment for studies offering intervention to individuals involved in a traumatic event irrespective of their symptoms.

Figure 3. Forest plot of PTSD severity, post treatment for studies of interventions begun within three months with the aim of preventing PTSD or ongoing distress in individuals with traumatic stress symptoms.

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