In brief
A 2020 mixed-methods systematic review of 104 RCTs finding that psychological therapies, especially trauma-focused and phase-based approaches, are effective and acceptable post-treatment for reducing PTSD and depression in complex trauma, with limited medication benefit and gaps for veterans and long-term outcomes.
What this article is about
Quick Answer
A 2020 mixed-methods systematic review of 104 RCTs finding that psychological therapies, especially trauma-focused and phase-based approaches, are effective and acceptable post-treatment for reducing PTSD and depression in complex trauma, with limited medication benefit and gaps for veterans and long-term outcomes.
Student takeaways
Key Takeaways
- Across 104 randomized controlled trials and 9 non-randomized controlled trials, psychological interventions were superior to control at reducing PTSD symptoms post-treatment (standardized mean difference -0.90, 95 percent CI -1.14 to -0.66; 39 trials) and also reduced depression, but not anxiety.
- Trauma-focused therapies were the most effective interventions across all populations for both PTSD and depression, and multicomponent and trauma-focused interventions were effective for negative self-concept.
- Phase-based approaches were superior to control for PTSD and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems.
- For medications, only antipsychotic medication was effective for reducing PTSD symptoms, and medications were not effective for the mental comorbidities that accompany complex trauma.
- Psychological interventions were less effective in veterans and had less impact on complex-PTSD-associated symptoms; qualitatively, interventions were more acceptable when service users could identify benefits and when care fit their personal and social needs.
Student summary
Why This Research Matters
The INCiTE review is a large mixed-methods systematic review, published in the UK journal Health Technology Assessment in 2020, that asks which treatments help adults who have a history of complex traumatic events. Complex trauma usually means repeated or prolonged events, for example ongoing abuse, and people who live through it often have post-traumatic stress disorder (PTSD) along with other mental health problems. The review's goal was to identify promising psychological and non-drug treatments, and to judge how acceptable they are to the people receiving them, so that future research can focus on the best candidates.
To do this, the team searched many major databases, including CINAHL, MEDLINE, EMBASE, PsycINFO, the Cochrane CENTRAL register, and others, for studies conducted up to 2017. They combined two kinds of evidence. First, they pooled numerical results from trials in a meta-analysis to see how well treatments reduced symptoms. Second, they gathered qualitative studies, which are based on people's experiences and views, to understand what made treatments acceptable. Risk of bias was assessed with the Cochrane tool and a checklist adapted from the National Institute for Health and Care Excellence, and confidence in the qualitative findings was rated using the GRADE-CERQual approach. The review included 104 randomized controlled trials and 9 non-randomized controlled trials, plus 9 qualitative studies drawn from 4,324 records.
The main quantitative finding was that psychological interventions were better than control conditions at reducing PTSD symptoms right after treatment. The pooled effect was a standardized mean difference of -0.90 (95 percent confidence interval -1.14 to -0.66), based on 39 trials, which is a large effect in statistical terms. Psychological treatments also helped with depression, but the review did not find a benefit for anxiety. Among the different approaches, trauma-focused therapies were the most effective across all the groups studied, for both PTSD and depression. Multicomponent and trauma-focused interventions helped with negative self-concept, meaning how people see themselves. Phase-based approaches, which build stabilization and coping skills before processing the trauma, were also better than control for PTSD and depression, and showed the most benefit for managing emotional dysregulation and interpersonal problems, which are common in complex trauma.
For medication, the picture was much narrower. Only antipsychotic medication was effective for reducing PTSD symptoms, and medications were not effective for the other mental health problems that often accompany complex trauma. It is important to read this carefully: it does not mean patients should start or stop any medication on their own. Prescribing decisions depend on an individual assessment by a qualified clinician, and this review reports group-level research evidence, not personal treatment advice.
The people studied fell into several subgroups: military veterans, survivors of childhood sexual abuse, war-affected people, refugees, and survivors of domestic violence. The review found that the psychological treatments were less effective in veterans, and that they had less impact on the symptoms specifically associated with complex PTSD. From the qualitative side, treatments were more acceptable when people could identify benefits for themselves and when care was delivered in ways that fit their personal and social needs, a reminder that engagement and fit matter, not just the technique.
The authors were honest about the review's limits. They could not draw conclusions about long-term effectiveness, because the evidence did not support it. Some important groups were under-represented, including people with conditions like borderline personality disorder and people in prisons or humanitarian crises. The review is registered with PROSPERO (CRD42017055523) and was funded by the UK's National Institute for Health Research.
For nursing students, INCiTE is a useful example of how high-quality evidence is built and appraised. It shows the value of combining numbers with lived experience, the difference between short-term and long-term evidence, and why what works on average still has to be tailored to the individual. The overall message it supports is cautious and clinically sensible: evidence-based psychological therapies, especially trauma-focused and phase-based approaches, are effective and acceptable right after treatment for reducing PTSD and depression in people with complex trauma, while gaps remain for veterans, for complex-PTSD-specific symptoms, and for long-term outcomes. A caution: this is a research summary, not a treatment plan, and people with complex trauma deserve individualized care from qualified professionals.
Source abstract
Study Overview
Background: People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people. Objective: To identify candidate psychological and non-pharmacological treatments for future research. Design: Mixed-methods systematic review. Participants: Adults aged ≥ 18 years with a history of complex traumatic events. Interventions: Psychological interventions versus control or active control; pharmacological interventions versus placebo. Main outcome measures: Post-traumatic stress disorder symptoms, common mental health problems and attrition. Data sources: Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017. Review methods: Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist. Results: One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference –0.90, 95% confidence interval –1.14 to –0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs. Limitations: Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented. Conclusions: Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder. Future work: Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities. Study registration: This study is registered as PROSPERO CRD42017055523. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.
Evidence appraisal
Main Findings
- Across 104 randomized controlled trials and 9 non-randomized controlled trials, psychological interventions were superior to control at reducing PTSD symptoms post-treatment (standardized mean difference -0.90, 95 percent CI -1.14 to -0.66; 39 trials) and also reduced depression, but not anxiety.
- Trauma-focused therapies were the most effective interventions across all populations for both PTSD and depression, and multicomponent and trauma-focused interventions were effective for negative self-concept.
- Phase-based approaches were superior to control for PTSD and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems.
- For medications, only antipsychotic medication was effective for reducing PTSD symptoms, and medications were not effective for the mental comorbidities that accompany complex trauma.
- Psychological interventions were less effective in veterans and had less impact on complex-PTSD-associated symptoms; qualitatively, interventions were more acceptable when service users could identify benefits and when care fit their personal and social needs.
Critical appraisal
Limitations
- The review could not assess long-term effectiveness, so its conclusions are limited to post-treatment, shorter-term outcomes.
- Certain groups were under-represented, including people with comorbid conditions such as borderline personality disorder and populations from prisons and humanitarian crises.
- Searches were conducted up to 2017 (April to August 2017), so trials published since then are not included.
Classroom use
Discussion Questions
- Why does combining a meta-analysis with a qualitative synthesis give a fuller picture than either approach alone?
- What does a standardized mean difference of -0.90 mean, and why can effect sizes be more informative than p-values?
- Why might trauma-focused and phase-based therapies suit people with complex trauma?
- Why is it important that the review could not assess long-term effectiveness?
- What could explain the smaller treatment effects seen in veterans, and how would you study it?
- How should the finding that only antipsychotics reduced PTSD symptoms be communicated to patients safely?
- Why does acceptability, meaning service users seeing benefits and care fitting their needs, matter for outcomes and attrition?
- What are the consequences of under-representing people with borderline personality disorder, prisoners, and those in humanitarian crises?
- How current is evidence with a 2017 search cutoff, and how would you check for newer trials?
- How can a nurse turn what works on average into individualized, patient-centered care?
Search-ready answers
Frequently asked questions
What does INCiTE conclude overall?
That evidence-based psychological therapies, especially trauma-focused and phase-based approaches, are effective and acceptable post-treatment for reducing PTSD and depression in people with complex trauma; the results found no benefit for anxiety, and effects were smaller in veterans.
Should a patient change their medication based on this review?
No. Only antipsychotics reduced PTSD symptoms at a group level; prescribing is an individualized clinical decision made with a qualified clinician, and no one should adjust medication based on this summary.
What is a trauma-focused therapy?
A therapy that directly addresses traumatic memories and their meanings. The review found trauma-focused therapies were the most effective across the populations studied.
What are phase-based approaches?
Approaches that build stabilization and coping skills before processing the trauma. The review found them most helpful for emotional dysregulation and interpersonal problems.
Why combine quantitative and qualitative evidence?
To learn both whether treatments work, through the meta-analysis, and whether they are acceptable to the people receiving them, through the qualitative synthesis.
Does the review tell us about long-term results?
No. It could not assess long-term effectiveness, so its conclusions apply to post-treatment outcomes.
Who was under-represented in the evidence?
People with comorbid conditions such as borderline personality disorder, and populations from prisons and humanitarian crises.
Why might interventions be less effective for veterans?
The review reports smaller effects in veterans, but this record does not fully explain the mechanism; it is a noted finding, not an established cause.
How current is the evidence?
Searches ran up to 2017, so more recent trials are not included in the review.
How should nurses use this review?
To support access to evidence-based psychological therapy, promote engagement and acceptability, and tailor care, while recognizing the gaps and the need for individualized, professional treatment.