A systematic review and meta-analysis of PTSD symptoms at mid-treatment during trauma-focused treatment for PTSD

There is concern that trauma memory processing in psychological therapies leads to PTSD symptom exacerbation. We compared PTSD symptoms at mid-treatment in trauma-focused psychological therapy to control groups. We systematically searched multiple databases and searched grey literature. We included randomised controlled trials involving adults comparing trauma-focused psychological interventions with active non-trauma-focused interventions or waitlist conditions. Twenty-three studies met our inclusion criteria. We found no evidence of PTSD symptom exacerbation at mid-treatment in trauma-focused interventions compared to control groups (g=−.16, [95 % confidence interval, CI, −.34,.03]). Sensitivity analyses with high quality studies (risk of bias assessment ≥ 7; g=−.25; [95 % CI −.48, −.03], k = 12) and studies with passive controls (g=−.32; [95 % CI −.59, −.05], k = 8) yielded small effect sizes favouring trauma-focused interventions. At post-treatment, trauma-focused interventions yielded a medium effect on PTSD symptoms compared to all controls (g=−.57; [CI −.79, −.35], k = 23). Regarding depression, trauma-focused interventions yielded a small effect size compared to controls at mid-treatment (g=−.23; [95 % CI −.39, −.08], k = 12) and post-treatment (g=−.45; [CI −.66, −.25], k = 12). This meta-analysis found no evidence that trauma-focused psychotherapies elicit symptom exacerbation at mid-treatment in terms of PTSD or depression symptoms. Instead, this meta-analysis suggests that the benefits of trauma-focused interventions can be experienced through improved depression and possibly PTSD before the conclusion of therapy. However, it is possible that symptom exacerbation occurred before mid-treatment and/or that people who experience symptom exacerbation drop out of studies and so are not included in the analysis.