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.