Post-traumatic stress disorder (PTSD) is a mental condition defined by distressing psychological symptoms following the occurrence of a threatening event, which can be experienced directly or witnessed. Epidemiological studies suggest that in the general population the lifetime exposure to one or more traumatic events is as high as 70%.
The symptoms are many and include intrusive memories of the traumatic event and negative feelings of guilt and shame. The patients usually are hyperalert and struggle to concentrate or to sleep. This distress compromises the capacity to work or interact in a social context, thus causing remarkable economic burden due to associated job loss. Furthermore, the rate of suicide is 13 times higher in people with PTSD than in those without this disorder.
In this scenario, internet-based cognitive and behavioural therapy (I-C/BT) aims to enhance functioning of people with PTSD, enabling them to cope with maladaptive thoughts and behaviours. Particularly I-C/BT consists of internet adaptations of four elements of in-person CBT: psychoeducation, anxiety management techniques, in vivo exposure or via imagination, and cognitive restructuring. I-C/BT is an appealing alternative to those who may not commit to in-person therapy, reducing healthcare costs and widening the access to these therapies especially considering modern times and COVID-19 lockdown restrictions.
Moreover, modern guideline recommendations for PTSD include trauma-focused CBT, cognitive therapy (CT), prolonged exposure (PE), eye movement desensitisation, and reprocessing (EMDR).
This review investigated whether I-C/BT was more effective than no therapy, conventional therapy, or other internet delivered therapies for adults with PTSD.
This review is important for
People with PTSD, their loved ones/caregivers, health professionals caring for this population, general practitioners, researchers, and policymakers.
Outcomes of this review
This is an update of a Cochrane Systematic Review (CSRs) published in 2018. The primary outcomes analysed were the severity of PTSD symptoms and dropouts. The secondary outcomes analysed were severity of depressive and anxiety symptoms, cost-effectiveness, adverse events, treatment acceptability, and quality of life. The CSR included 13 randomised control trials (RCTs) published between 1970 and June 5, 2020, with 808 adult participants. Results showed that it was uncertain whether I-C/BT compared with face-to-face non-CBT reduced PTSD symptoms or dropouts rates. On the other hand, compared with wait list, I-C/BT was associated with a clinically important reduction in PTSD post-treatment; whereas there may be no difference in dropout rates between the I-C/BT and wait-list groups (very low-certainty evidence).
I-C/BT may be no more effective than wait list at reducing the risk of a diagnosis of PTSD after treatment (very low-certainty evidence). I-C/BT may be associated with a clinically important reduction in symptoms of depression and anxiety post-treatment. Finally, there was no statistically significant difference in PTSD, anxiety, and depressive symptoms as well as dropout rates post-treatment between the I-C/BT and I-non-C/BT groups (very low-certainty evidence).
There were no data regarding cost-effectiveness, and data on adverse events were uncertain, with only one study showing an absence of adverse events.
These results must be interpreted with caution because (i) it was impossible to blind participants or therapists; (ii) only three studies published study protocols; (iii) the results are not completely generalizable to low- and middle-income countries; (iv) the authors could not be certain of the number of participants who had PTSD symptoms for at least one month, which is a diagnostic criterion; (v) subgroup analyses could not be performed to assess the effect of: type of assistance, type of recruitment, type of CBT, baseline symptom severity, and trauma type and context; and (vi) I-C/BT programmes were heterogeneous.
Author’s conclusion of the review
In the field of I-C/BT, PTSD treatment lags behind other disorders, and the world pandemic underlined even more the necessity to exploit internet delivered treatment. To date there are few studies on the efficacy of I-C/BT for PTSD. The authors found a positive effect of I-C/BT for PTSD, but the certainty of the evidence was very low. This review update also identified many planned and ongoing studies, which are indeed required to determine if I-C/BT is as effective as current first-line interventions. Those studies will be necessary to better analyse the mechanisms of change, to determine specific guidance, to measure cost-effectiveness and adverse events, and to determine factors associated with efficacy and dropout.
Future recommendations
The authors recommended that further studies are needed, particularly to find out (a) predictors of outcome and dropout; (b) if I-C/BT may be used to treat complex PTSD; (c) cost-effectiveness, and (d) aspects associated with efficacy and acceptability.
commented by Robin Kuruvila Sentinella