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COVID-19 will cause normal feelings of worry and stress and many of those who experience higher levels of distress will experience resolution of their symptoms as society returns to pre-COVID-19 functioning. Only a minority are likely to develop a psychiatric disorder. Certain individuals may be vulnerable to experiencing persisting symptoms, such as those with pre-existing comorbidity. Management approaches could centre around using collaborative approaches to provide and build on already existing socioeconomic support structures, the avoidance of over-medicalisation, watchful waiting and finally treating those who do meet the criteria for psychiatric diagnosis. Primary care clinicians are likely be the first healthcare point of contact for most COVID-19 related distress and it is important that they are able to provide evidence based and evidence informed responses, which includes social, psychological and pharmacological approaches. This expert opinion paper serves to summarise some approaches, based primarily on indirect extrapolation of evidence concerning the general management of psychological distress, in the absence of COVID-19 specific evidence, to assist primary care clinicians in their assessment and management of COVID-19 related distress.

The epidemic of the 2019 novel coronavirus SARS-CoV-2, causing the coronavirus disease 2019 (COVID-19) is a global public health emergency with multifaceted severe consequences for people's lives and their mental health. In this article, as members of the European College of Neuropsychopharmacology (ECNP) Resilience, we will discuss the urgent need for a focus on resilience during the current coronavirus pandemic. Resilience is pivotal to cope with stress and vital to stay in balance. We will discuss the importance of resilience at the individual and societal level, but also the implication for patients with a psychiatric condition and health care workers. We not only advocate for an increased focus on mental health during the coronavirus pandemic but also highlight the urgent need of augmenting our focus on resilience and on strategies to enhance it.\ud \ud The epidemic of the 2019 novel coronavirus SARS-CoV-2, causing the coronavirus disease 2019 (COVID-19), first expanded within the Wuhan region in China and quickly spread to Europe and to the rest of the world (Zhou et al., 2020). The outbreak of COVID-19 is a global public health emergency with multifaceted severe consequences for people's lives and their mental health. In this article, as members of the European College of Neuropsychopharmacology (ECNP) Resilience, we will discuss the urgent need for a focus on resilience during the current coronavirus pandemic. Resilience is pivotal to cope with stress and vital to stay in balance. We will discuss the importance of resilience at the individual and societal level, but also the implication for patients with a psychiatric condition and health care workers.

Funding Information: This work was supported by the National Institute of Mental Health / U.S. Army Medical Research and Development Command (Grant No. R01MH106595 [to CMN, IL, MBS, KJRe, and KCK], National Institutes of Health (Grant No. 5U01MH109539 to the Psychiatric Genomics Consortium ), and Brain & Behavior Research Foundation (Young Investigator Grant [to KWC]). Genotyping of samples was provided in part through the Stanley Center for Psychiatric Genetics at the Broad Institute supported by Cohen Veterans Bioscience . Statistical analyses were carried out on the LISA/Genetic Cluster Computer ( https://userinfo.surfsara.nl/systems/lisa ) hosted by SURFsara. This research has been conducted using the UK Biobank resource (Application No. 41209). This work would have not been possible without the financial support provided by Cohen Veterans Bioscience, the Stanley Center for Psychiatric Genetics at the Broad Institute, and One Mind. Funding Information: MBS has in the past 3 years received consulting income from Actelion, Acadia Pharmaceuticals, Aptinyx, Bionomics, BioXcel Therapeutics, Clexio, EmpowerPharm, GW Pharmaceuticals, Janssen, Jazz Pharmaceuticals, and Roche/Genentech and has stock options in Oxeia Biopharmaceuticals and Epivario. In the past 3 years, NPD has held a part-time paid position at Cohen Veterans Bioscience, has been a consultant for Sunovion Pharmaceuticals, and is on the scientific advisory board for Sentio Solutions for unrelated work. In the past 3 years, KJRe has been a consultant for Datastat, Inc., RallyPoint Networks, Inc., Sage Pharmaceuticals, and Takeda. JLM-K has received funding and a speaking fee from COMPASS Pathways. MU has been a consultant for System Analytic. HRK is a member of the Dicerna scientific advisory board and a member of the American Society of Clinical Psychopharmacology Alcohol Clinical Trials Initiative, which during the past 3 years was supported by Alkermes, Amygdala Neurosciences, Arbor Pharmaceuticals, Dicerna, Ethypharm, Indivior, Lundbeck, Mitsubishi, and Otsuka. HRK and JG are named as inventors on Patent Cooperative Treaty patent application number 15/878,640, entitled “Genotype-guided dosing of opioid agonists,” filed January 24, 2018. RP and JG are paid for their editorial work on the journal Complex Psychiatry. OAA is a consultant to HealthLytix. All other authors report no biomedical financial interests or potential conflicts of interest. Funding Information: This work was supported by the National Institute of Mental Health/ U.S. Army Medical Research and Development Command (Grant No. R01MH106595 [to CMN, IL, MBS, KJRe, and KCK], National Institutes of Health (Grant No. 5U01MH109539 to the Psychiatric Genomics Consortium), and Brain & Behavior Research Foundation (Young Investigator Grant [to KWC]). Genotyping of samples was provided in part through the Stanley Center for Psychiatric Genetics at the Broad Institute supported by Cohen Veterans Bioscience. Statistical analyses were carried out on the LISA/Genetic Cluster Computer (https://userinfo.surfsara.nl/systems/lisa) hosted by SURFsara. This research has been conducted using the UK Biobank resource (Application No. 41209). This work would have not been possible without the financial support provided by Cohen Veterans Bioscience, the Stanley Center for Psychiatric Genetics at the Broad Institute, and One Mind. This material has been reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation and/or publication. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting true views of the U.S. Department of the Army or the Department of Defense. We thank the investigators who comprise the PGC-PTSD working group and especially the more than 206,000 research participants worldwide who shared their life experiences and biological samples with PGC-PTSD investigators. We thank Mark Zervas for his critical input. Full acknowledgments are in Supplement 1. MBS has in the past 3 years received consulting income from Actelion, Acadia Pharmaceuticals, Aptinyx, Bionomics, BioXcel Therapeutics, Clexio, EmpowerPharm, GW Pharmaceuticals, Janssen, Jazz Pharmaceuticals, and Roche/Genentech and has stock options in Oxeia Biopharmaceuticals and Epivario. In the past 3 years, NPD has held a part-time paid position at Cohen Veterans Bioscience, has been a consultant for Sunovion Pharmaceuticals, and is on the scientific advisory board for Sentio Solutions for unrelated work. In the past 3 years, KJRe has been a consultant for Datastat, Inc. RallyPoint Networks, Inc. Sage Pharmaceuticals, and Takeda. JLM-K has received funding and a speaking fee from COMPASS Pathways. MU has been a consultant for System Analytic. HRK is a member of the Dicerna scientific advisory board and a member of the American Society of Clinical Psychopharmacology Alcohol Clinical Trials Initiative, which during the past 3 years was supported by Alkermes, Amygdala Neurosciences, Arbor Pharmaceuticals, Dicerna, Ethypharm, Indivior, Lundbeck, Mitsubishi, and Otsuka. HRK and JG are named as inventors on Patent Cooperative Treaty patent application number 15/878,640, entitled ?Genotype-guided dosing of opioid agonists,? filed January 24, 2018. RP and JG are paid for their editorial work on the journal Complex Psychiatry. OAA is a consultant to HealthLytix. All other authors report no biomedical financial interests or potential conflicts of interest. Publisher Copyright: © 2021 Society of Biological Psychiatry Background: Posttraumatic stress disorder (PTSD) is heritable and a potential consequence of exposure to traumatic stress. Evidence suggests that a quantitative approach to PTSD phenotype measurement and incorporation of lifetime trauma exposure (LTE) information could enhance the discovery power of PTSD genome-wide association studies (GWASs). Methods: A GWAS on PTSD symptoms was performed in 51 cohorts followed by a fixed-effects meta-analysis (N = 182,199 European ancestry participants). A GWAS of LTE burden was performed in the UK Biobank cohort (N = 132,988). Genetic correlations were evaluated with linkage disequilibrium score regression. Multivariate analysis was performed using Multi-Trait Analysis of GWAS. Functional mapping and annotation of leading loci was performed with FUMA. Replication was evaluated using the Million Veteran Program GWAS of PTSD total symptoms. Results: GWASs of PTSD symptoms and LTE burden identified 5 and 6 independent genome-wide significant loci, respectively. There was a 72% genetic correlation between PTSD and LTE. PTSD and LTE showed largely similar patterns of genetic correlation with other traits, albeit with some distinctions. Adjusting PTSD for LTE reduced PTSD heritability by 31%. Multivariate analysis of PTSD and LTE increased the effective sample size of the PTSD GWAS by 20% and identified 4 additional loci. Four of these 9 PTSD loci were independently replicated in the Million Veteran Program. Conclusions: Through using a quantitative trait measure of PTSD, we identified novel risk loci not previously identified using prior case-control analyses. PTSD and LTE have a high genetic overlap that can be leveraged to increase discovery power through multivariate methods. publishersversion published

The global public health crisis caused by COVID-19 has lasted longer than many of us would have hoped and expected. With its high uncertainty and limited control, the COVID-19 pandemic has undoubtedly asked a lot from all of us. One important central question is: how resilient have we proved in face of the unprecedented and prolonged coronavirus pandemic? There is a vast and rapidly growing literature that has examined the impact of the pandemic on mental health both on the shorter (2020) and longer (2021) term. This not only concerns pandemic-related effects on resilience in the general population, but also how the pandemic has challenged stress resilience and mental health outcomes across more specific vulnerable population groups: patients with a psychiatric disorder, COVID-19 diagnosed patients, health care workers, children and adolescents, pregnant women, and elderly people. It is challenging to keep up to date with, and interpret this rapidly increasing scientific literature. In this review, we provide a critical overview on how the COVID-19 pandemic has impacted mental health and how human stress resilience has been shaped by the pandemic on the shorter and longer term. The vast literature is dominated by a wealth of data which are, however, not always of the highest quality and heavily depend on online and self-report surveys. Nevertheless, it appears that we have proven surprisingly resilient over time, with fast recovery from COVID-19 measures. Still, vulnerable groups such as adolescents and health care personnel that have been severely impacted by the COVID-19 pandemic do exist. Large interindividual differences exist, and for future pandemics there is a clear need to comprehensively and integratively assess resilience from the start to provide personalized help and interventions tailored to the specific needs for vulnerable groups.\ud •\ud The early stages of the COVID-19 pandemic were often associated with increased levels of distress and depressive and anxiety symptoms in the general population.\ud \ud •\ud A substantial group of individuals has been either largely unaffected or is even doing better during the pandemic.\ud \ud •\ud Longitudinal follow up showed remarkable signs of resilience.\ud \ud •\ud Health care workers appear to be at an increased risk of stress-related psychological symptoms.\ud \ud •\ud The mental health of children, adolescents, and students has been particularly affected by the pandemic.\ud \ud •\ud Elderly people are more vulnerable to the physical effects of COVID-19, but also report lower psychopathology during the pandemic.\ud \ud •\ud Individuals with an existing psychiatric disorder are experiencing detrimental impact on their mental health from the COVID-19 pandemic, but do not seem to have further increased symptom severity compared with their pre-pandemic levels.\ud \ud •\ud A high risk exists for psychiatric sequelae following a COVID-19 infection.\ud \ud •\ud Many methodological shortcomings occur in the current literature which is often cross-sectional and relies on self-report, and it is moreover hard to directly compare results across many of the studies.\ud \ud •\ud There is an urgent need for a personalized approach when it comes to identifying individuals at risk or resilient for the stressful effects of the COVID-19 pandemic.\ud \ud •\ud The effects of stress and the resilience capacity are dependent on (neuro)biological, psychological, and environmental factors and also are heavily dependent on an individual's unique context.

Translational research highlights the potential of novel 'memory consolidation/reconsolidation therapies' to treat re-experiencing symptoms and post-traumatic stress disorder (PTSD). This systematic review and meta-analysis assessed the efficacy of so-called memory consolidation/reconsolidation therapies in randomised controlled trials (RCTs) for prevention and treatment of PTSD and symptoms of re-experiencing in children and adults (PROSPERO: CRD42020171167). RCTs were identified and rated for risk of bias. Available data was pooled to calculate risk ratios (RR) for PTSD prevalence and standardised mean differences (SMD) for PTSD/re-experiencing severity. Twenty-five RCTs met inclusion criteria (16 prevention and nine treatment trials). The methodology of most studies had a significant risk of bias. We found a large effect of reconsolidation interventions in the treatment of PTSD (11 studies, n = 372, SMD: −1.42 (−2.25 to −0.58), and a smaller positive effect of consolidation interventions in the prevention of PTSD (12 studies, n = 2821, RR: 0.67 (0.50 to 0.90). Only three protocols (hydrocortisone for PTSD prevention, Reconsolidation of Traumatic Memories (RTM) for treatment of PTSD symptoms and cognitive task memory interference procedure with memory reactivation (MR) for intrusive memories) were superior to control. There is some emerging evidence of consolidation and reconsolidation therapies in the prevention and treatment of PTSD and intrusive memories specifically. Translational research should strictly adhere to protocols/procedures describing precise reconsolidation conditions (e.g. MR) to both increase the likelihood of positive findings and more confidently interpret negative findings of putative reconsolidation agents.

Background While research demonstrates that somatisation is highly correlated with post-traumatic stress disorder (PTSD), the relationship between International Classification of Diseases 11th edition (ICD-11) PTSD, complex PTSD (CPTSD) and somatisation has not previously been determined. Objective To determine the relationship between frequency and severity of somatisation and ICD-11 PTSD/CPTSD. Method This cross-sectional study included 222 individuals recruited to the National Centre for Mental Health (NCMH) PTSD cohort. We assessed rates of Patient Health Questionnaire 15 (PHQ-15) somatisation stratified by ICD-11 PTSD/CPTSD status. Path analysis was used to explore the relationship between PTSD/CPTSD and somatisation, including number of traumatic events, age, and gender as controls. Results 70% (58/83) of individuals with CPTSD had high PHQ-15 somatisation symptom severity compared with 48% (12/25) of those with PTSD (chi-square: 95.1, p value, Highlights • People with CPTSD had a higher prevalence of co-morbid somatisation. • People with CPTSD had a worse somatisation symptom severity. • The core features of PTSD predicted somatisation.

Objective:Post-traumatic stress disorder involves excessive retrieval of traumatic memories. Glucocorticoids impair declarative memory retrieval. This preliminary study examined the effect of acute hydrocortisone administration on brain activation in individuals with earthquake-related post-traumatic stress disorder compared with earthquake-exposed healthy individuals, during retrieval of traumatic memories.Method:Participants exposed to earthquakes with ( n = 11) and without post-traumatic stress disorder ( n = 11) underwent two functional magnetic resonance imaging scans, 1-week apart, in a double-blind, placebo-controlled, counter-balanced design. On one occasion, they received oral hydrocortisone (20 mg), and on the other, placebo, 1 hour before scanning. Symptom provocation involved script-driven imagery (traumatic and neutral scripts) and measures of self-reported anxiety.Results:Arterial spin labelling showed that both post-traumatic stress disorder and trauma-exposed controls had significantly reduced cerebral blood flow in response to retrieval of traumatic versus neutral memories in the right hippocampus, parahippocampal gyrus, calcarine sulcus, middle and superior temporal gyrus, posterior cingulate, Heschl’s gyrus, inferior parietal lobule, angular gyrus, middle occipital gyrus, supramarginal gyrus, lingual gyrus and cuneus, and the left prefrontal cortex. Hydrocortisone resulted in non-significant trends of increasing subjective distress and reduced regional cerebral blood flow in the left inferior frontal gyrus, left anterior cingulate gyrus, middle temporal gyrus, cerebellum, postcentral gyrus and right frontal pole, during the trauma script.Conclusion:Findings do not fit with some aspects of the accepted neurocircuitry model of post-traumatic stress disorder, i.e., failure of the medial prefrontal cortex to quieten hyperresponsive amygdala activity, and the potential therapeutic benefits of hydrocortisone. They do, however, provide further evidence that exposure to earthquake trauma, regardless of whether post-traumatic stress disorder eventuates, impacts brain activity and highlights the importance of inclusion of trauma-exposed comparisons in studies of post-traumatic stress disorder.

Repetitive transcranial magnetic stimulation (rTMS) as a treatment for posttraumatic stress disorder (PTSD) has gained interest over the past two decades. However, it has yet to be recommended in major treatment guidelines. We conducted a systematic review of randomized controlled trials to examine the efficacy of rTMS for PTSD. Thirteen studies with 549 participants were included in this review. We compared the effects of (1) rTMS versus sham, and (2) high-frequency (HF) versus low-frequency (LF) rTMS, on posttreatment PTSD scores and other secondary outcomes. We calculated the standardized mean differences (SMD) to determine the direction of effects, and unstandardized mean differences to estimate the magnitude of efficacy. At post-treatment, rTMS was superior to sham comparison in reducing PTSD (SMD = −1.13, 95% CI: −2.10 to −0.15) and depression severity (SMD = −0.83, 95% CI: −1.30 to −0.36). The quality of evidence, however, was rated very low due to small samples sizes, treatment heterogeneity, inconsistent results, and an imprecise pooled effect. HF rTMS was associated with slightly improved, albeit imprecise, outcomes compared to LF rTMS on PTSD (SMD = −0.19, 95% CI: −1.39 to 1.00) and depression (SMD = −1.09, 95% CI: −1.65 to −0.52) severity. Further research is required to advance the evidence on this treatment.

To explore in-depth the views on Internet-based psychological therapies and their implementation from the perspective of National Health Service (NHS) commissioners and managers.Qualitative interview study.Ten NHS commissioners and managers participated in a semi-structured, co-produced interview. Each transcribed interview was double-coded and thematically analysed using The Framework Method.Interviews generated three main themes. (1) Capacity issues across psychological therapy services create barriers to face-to-face therapies, and Internet-based interventions offer a solution. (2) Despite reservations, there is growing acceptance of Internet-based therapies. Different ways of connecting with patients are required, and Internet-based treatments are accessible and empowering treatment options, with guided self-help (GSH) preferred. Internet-based interventions may however exclude some individuals and be a threat to the therapeutic relationship between patient and practitioner. (3) Successful roll-out of Internet-based interventions would be facilitated by a strong empirical- or practice-based evidence, a national coordinated approach and timely training and supervision. Barriers to the roll-out include digital intervention set-up costs and delays due to NHS inflexibility.The study highlights factors influencing access to Internet-based therapies, important given the rapid evolution of e-therapies, and particularly timely given increasing use of remote therapies due to COVID-19 restrictions. Interviewees were open to Internet-based approaches, particularly GSH interventions, so long as they do not compromise on therapy quality. Interviewees acknowledged implementation may be challenging, and recommendations were offered.There is a shift in practice and increasingly positive views from NHS staff around remote psychological therapies and different ways of connecting with patients, particularly since the COVID-19 pandemic. There is a strong preference for Internet-based psychological interventions that are guided and that include built-in outcome measures co-produced with service users. There is a need to raise awareness of the growing evidence base for Internet-based psychological therapies, including research examining therapeutic alliance across Internet-based and face-to-face therapies. Challenges implementing Internet-based psychological therapies include therapist resistance to changing working practices in general, and inflexibility of the NHS, and national, coordinated implementation efforts are encouraged.

Background: An increasing body of research highlights reconsolidation-based therapies as emerging treatments for post-traumatic stress disorder (PTSD). The Rewind Technique is a non-pharmacological reconsolidation-based therapy with promising early results, which now requires evaluation through an RCT. Objectives: This is a preliminary efficacy RCT to determine if the Rewind Technique is likely to be a good candidate to test against usual care in a future pragmatic efficacy RCT. Methods: 40 participants will be randomised to receive either the Rewind Technique immediately, or after an 8 week wait. The primary outcome will be PTSD symptom severity as measured by the Clinician-Administered PTSD Scale for DSM5 (CAPS-5) at 8 and 16 weeks post-randomisation. Secondary outcome measures include the PTSD Checklist (PCL-5), International Trauma Questionnaire (ITQ), Patient Health Questionnaire (PHQ-9), the General Anxiety Disorder-7 (GAD-7), Insomnia Severity Index, the Euro-Qol-5D (EQ5D-5 L), the prominence of re-experiencing specific symptoms (CAPS-5) and an intervention acceptability questionnaire to measure tolerability of the intervention. Conclusions: This study will be the first RCT to assess the Rewind Technique. Using a cross-over methodology we hope to rigorously assess the efficacy and tolerability of Rewind using pragmatic inclusion criteria. Potential challenges include participant recruitment and retention. Trial registration: ISRCTN91345822, HIGHLIGHTS This study will be the first RCT to rigorously assess the efficacy and tolerability of the Rewind Technique.

Background: Pharmacological approaches are widely used for post-traumatic stress disorder (PTSD) despite uncertainty over efficacy. Objectives: To determine the efficacy of all pharmacological approaches, including monotherapy, augmentation and head-to-head approaches (drug versus drug, drug versus psychotherapy), in reducing PTSD symptom severity. Method: A systematic review and meta-analysis of randomised controlled trials were undertaken; 115 studies were included. Results: Selective serotonin reuptake inhibitors (SSRIs) were found to be statistically superior to placebo in reduction of PTSD symptoms but the effect size was small (standardised mean difference −0.28, 95% CI −0.39 to −0.17). For individual monotherapy agents compared to placebo in two or more studies, we found small statistically significant evidence for the antidepressants fluoxetine, paroxetine, sertraline, venlafaxine and the antipsychotic quetiapine. For pharmacological augmentation, we found small statistically significant evidence for prazosin and risperidone. Conclusions: Some medications have a small positive effect on reducing PTSD symptom severity and can be considered as potential monotherapy treatments; these include fluoxetine, paroxetine, sertraline, venlafaxine and quetiapine. Two medications, prazosin and risperidone, also have a small positive effect when used to augment pharmacological monotherapy. There was no evidence of superiority for one intervention over another in the small number of head-to-head comparison studies., HIGHLIGHTS • Our review found evidence of a small positive effect for a handful of medications, which can reduce the symptom severity in post-traumatic stress disorder. • These were fluoxetine, paroxetine, sertraline, venlafaxine and the antipsychotic quetiapine when used as monotherapy, prazosin and risperidone for augmentation.

Background: Pharmacological-assisted psychotherapies, using conventional and novel drug agents, are increasingly being used both in clinical and experimental research settings, respectively. Objective: To determine the efficacy of conventional and novel pharmacological-assisted psychotherapies in reducing PTSD symptom severity. Method: A systematic review and meta-analysis of randomised-controlled trials were undertaken; 21 studies were included. Results: MDMA-assisted therapy was found to statistically superior to active and inactive placebo-assisted therapy in reduction of PTSD symptoms (standardised mean difference −1.09, 95% CI −1.60 to −0.58). There was no evidence of superiority over placebo for any other intervention. Conclusions: MDMA-assisted therapy demonstrated an impressive effect size; however, it is difficult to have confidence at this stage in this intervention due to the small numbers of participants included, and more research in this area is needed. There was no evidence to support the efficacy of any other drug-assisted interventions., Summary HIGHLIGHTS • We found that MDMA-assisted therapy is a novel and promising new treatment for severe PTSD. • Despite demonstrating an impressive effect size, more research is needed due to the small numbers of participants included. • We did not find evidence to recommend any other drug-assisted psychological intervention.

Post-traumatic stress disorder is a common condition that affects millions of people across the world. Up to date recommendations based on the best available evidence are vital to prevent and treat this debilitating condition. In this issue, we are bringing together a series of systematic reviews and meta-analyses that underpinned the development of the 2018 International Society for Traumatic Stress Studies Guidelines. The strongest evidence was found for psychological treatments for PTSD, in particular for cognitive behavioural therapy with a trauma focus (CBT-TF)(generic), cognitive processing therapy (CPT), cognitive therapy (CT), eye movement desensitisation and reprocessing (EMDR) and prolonged exposure (PE). For the subgroup of military personnel and veterans, results were less impressive. Dropout from trauma-focused psychological treatments was higher than for other forms of psychological treatment for PTSD in adults. For early interventions, CBT-TF, CT and EMDR were recommended. With regard to pharmacological approaches, a number of them were effective but with a low effect size. Of the pharmacologically assisted psychotherapies, MDMA-assisted psychotherapy was promising. Six complementary and alternative approaches showed emerging evidence. We now have an evidence base for a diverse range of pharmacological, psychological and other approaches that should facilitate their implementation and lead to the more effective management of people affected by traumatic events., HIGHLIGHTS • A diverse range of pharmacological, psychological and other approaches now have an evidence base for the prevention and treatment of PTSD.• This editorial introduces the EJPT special issue that considers these interventions and their relative strengths in more detail.

Background: Despite the established efficacy of psychological therapies for post-traumatic stress disorder (PTSD) there has been little systematic exploration of dropout rates.\ud Objective: To ascertain rates of dropout across different modalities of psychological therapy for PTSD and to explore potential sources of heterogeneity.\ud Method: A systematic review of dropout rates from randomized controlled trials (RCTs) of psychological therapies was conducted. The pooled rate of dropout from psychological therapies was estimated and reasons for heterogeneity explored using meta-regression.\ud Results:: The pooled rate of dropout from RCTs of psychological therapies for PTSD was 16% (95% CI 14–18%). There was evidence of substantial heterogeneity across studies. We found evidence that psychological therapies with a trauma-focus were significantly associated with greater dropout. There was no evidence of greater dropout from therapies delivered in a group format; from studies that recruited participants from clinical services rather than via advertisements; that included only military personnel/veterans; that were limited to participants traumatized by sexual traumas; that included a higher proportion of female participants; or from studies with a lower proportion of participants who were university educated.\ud Conclusions: Dropout rates from recommended psychological therapies for PTSD are high and this appears to be particularly true of interventions with a trauma focus. There is a need to further explore the reasons for dropout and to look at ways of increasing treatment retention.

Posttraumatic stress disorder (PTSD) and physical health problems, particularly somatic symptom disorder, are highly comorbid. Studies have only examined this co-occurrence at the disorder level rather than assessing the associations between specific symptoms. Using network analysis to identify symptoms that act as bridges between these disorders may allow for the development of interventions to specifically target this comorbidity. We examined the association between somatization and PTSD symptoms via network analysis. This included 349 trauma-exposed individuals recruited through the National Centre for Mental Health PTSD cohort who completed the Clinician-Administered PTSD Scale for DSM-5 and the Patient Health Questionnaire-15. A total of 215 (61.6%) individuals met the DSM-5 diagnostic criteria for PTSD. An exploratory graph analysis identified four clusters of densely connected symptoms within the overall network: PTSD, chronic pain, gastrointestinal issues, and more general somatic complaints. Sleep difficulties played a key role in bridging PTSD and somatic symptoms. Our network analysis demonstrates the distinct nature of PTSD and somatization symptoms, with this association connected by disturbed sleep.

Background: Non-pharmacological and non-psychological approaches to the treatment of post-traumatic stress disorder (PTSD) have often been excluded from systematic reviews and meta-analyses. Consequently, we know little regarding their efficacy. Objective: To determine the effect sizes of non-pharmacological and non-psychological treatment approaches for PTSD. Method: We undertook a systematic review and meta-analyses following Cochrane Collaboration guidelines. A pre-determined definition of clinical importance was applied to the results and the quality of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Results: 30 randomised controlled trials (RCTs) of a range of heterogeneous non- psychological and non-pharmacological interventions (28 in adults, two in children and adolescents) were included. There was emerging evidence for six different approaches (acupuncture, neurofeedback, saikokeishikankyoto (a herbal preparation), somatic experiencing, transcranial magnetic stimulation, and yoga). Conclusions: Given the level of evidence available, it would be premature to offer non- pharmacological and non-psychological interventions routinely, but those with evidence of efficacy provide alternatives for people who do not respond to, do not tolerate or do not want more conventional evidence-based interventions. This review should stimulate further research in this area.

Background Complex traumatic events associated with armed conflict, forcible displacement, childhood sexual abuse, and domestic violence are increasingly prevalent. People exposed to complex traumatic events are at risk of not only posttraumatic stress disorder (PTSD) but also other mental health comorbidities. Whereas evidence-based psychological and pharmacological treatments are effective for single-event PTSD, it is not known if people who have experienced complex traumatic events can benefit and tolerate these commonly available treatments. Furthermore, it is not known which components of psychological interventions are most effective for managing PTSD in this population. We performed a systematic review and component network meta-analysis to assess the effectiveness of psychological and pharmacological interventions for managing mental health problems in people exposed to complex traumatic events. Methods and findings We searched CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, International Pharmaceutical Abstracts, MEDLINE, Published International Literature on Traumatic Stress, PsycINFO, and Science Citation Index for randomised controlled trials (RCTs) and non-RCTs of psychological and pharmacological treatments for PTSD symptoms in people exposed to complex traumatic events, published up to 25 October 2019. We adopted a nondiagnostic approach and included studies of adults who have experienced complex trauma. Complex-trauma subgroups included veterans; childhood sexual abuse; war-affected; refugees; and domestic violence. The primary outcome was reduction in PTSD symptoms. Secondary outcomes were depressive and anxiety symptoms, quality of life, sleep quality, and positive and negative affect. We included 116 studies, of which 50 were conducted in hospital settings, 24 were delivered in community settings, seven were delivered in military clinics for veterans or active military personnel, five were conducted in refugee camps, four used remote delivery via web-based or telephone platforms, four were conducted in specialist trauma clinics, two were delivered in home settings, and two were delivered in primary care clinics; clinical setting was not reported in 17 studies. Ninety-four RCTs, for a total of 6,158 participants, were included in meta-analyses across the primary and secondary outcomes; 18 RCTs for a total of 933 participants were included in the component network meta-analysis. The mean age of participants in the included RCTs was 42.6 ± 9.3 years, and 42% were male. Nine non-RCTs were included. The mean age of participants in the non-RCTs was 40.6 ± 9.4 years, and 47% were male. The average length of follow-up across all included studies at posttreatment for the primary outcome was 11.5 weeks. The pairwise meta-analysis showed that psychological interventions reduce PTSD symptoms more than inactive control (k = 46; n = 3,389; standardised mean difference [SMD] = −0.82, 95% confidence interval [CI] −1.02 to −0.63) and active control (k-9; n = 662; SMD = −0.35, 95% CI −0.56 to −0.14) at posttreatment and also compared with inactive control at 6-month follow-up (k = 10; n = 738; SMD = −0.45, 95% CI −0.82 to −0.08). Psychological interventions reduced depressive symptoms (k = 31; n = 2,075; SMD = −0.87, 95% CI −1.11 to −0.63; I2 = 82.7%, p = 0.000) and anxiety (k = 15; n = 1,395; SMD = −1.03, 95% CI −1.44 to −0.61; p = 0.000) at posttreatment compared with inactive control. Sleep quality was significantly improved at posttreatment by psychological interventions compared with inactive control (k = 3; n = 111; SMD = −1.00, 95% CI −1.49 to −0.51; p = 0.245). There were no significant differences between psychological interventions and inactive control group at posttreatment for quality of life (k = 6; n = 401; SMD = 0.33, 95% CI −0.01 to 0.66; p = 0.021). Antipsychotic medicine (k = 5; n = 364; SMD = –0.45; –0.85 to –0.05; p = 0.085) and prazosin (k = 3; n = 110; SMD = −0.52; −1.03 to −0.02; p = 0.182) were effective in reducing PTSD symptoms. Phase-based psychological interventions that included skills-based strategies along with trauma-focused strategies were the most promising interventions for emotional dysregulation and interpersonal problems. Compared with pharmacological interventions, we observed that psychological interventions were associated with greater reductions in PTSD and depression symptoms and improved sleep quality. Sensitivity analysis showed that psychological interventions were acceptable with lower dropout, even in studies rated at low risk of attrition bias. Trauma-focused psychological interventions were superior to non-trauma-focused interventions across trauma subgroups for PTSD symptoms, but effects among veterans and war-affected populations were significantly reduced. The network meta-analysis showed that multicomponent interventions that included cognitive restructuring and imaginal exposure were the most effective for reducing PTSD symptoms (k = 17; n = 1,077; mean difference = −37.95, 95% CI −60.84 to −15.16). Our use of a non-diagnostic inclusion strategy may have overlooked certain complex-trauma populations with severe and enduring mental health comorbidities. Additionally, the relative contribution of skills-based intervention components was not feasibly evaluated in the network meta-analysis. Conclusions In this systematic review and meta-analysis, we observed that trauma-focused psychological interventions are effective for managing mental health problems and comorbidities in people exposed to complex trauma. Multicomponent interventions, which can include phase-based approaches, were the most effective treatment package for managing PTSD in complex trauma. Establishing optimal ways to deliver multicomponent psychological interventions for people exposed to complex traumatic events is a research and clinical priority., Peter Coventry and colleagues investigate evidence for the effectiveness and acceptability of psychological and pharmacological treatments for mental health problems following complex traumatic events., Author summary Why was the study done? Complex traumatic events are of a multiple or prolonged nature and are increasingly prevalent owing to unprecedented levels of population displacement, armed conflict, and increased recognition of childhood sexual abuse and domestic violence. People exposed to complex traumatic events are at risk of not only posttraumatic stress disorder (PTSD) but also other mental health problems. There are evidence-based psychological and pharmacological treatments for single-event PTSD, but it is not known if people who have experienced complex traumatic events can benefit and tolerate commonly available treatments. To inform treatment guidelines and future research, a broad evidence synthesis is needed that goes beyond existing knowledge to identify candidate interventions for mental health problems associated with complex trauma. What did the researchers do and find? We undertook a systematic review and meta-analysis of the effectiveness and acceptability of psychological and pharmacological treatments for mental health problems in veterans, refugees, victims of childhood sexual abuse and domestic violence, and war-affected populations. We used network meta-analysis to disentangle the relative contribution of different components of psychological treatments. The meta-analysis showed that psychological treatments are effective for treating PTSD, anxiety, and depression and improving sleep in people with a history of complex traumatic events. Pharmacological interventions were less effective than psychological interventions for treating PTSD symptoms and improving sleep. Trauma-focused treatments were the most effective approaches, but these treatments tended to be less effective in veterans and war-affected populations. Multicomponent interventions that included two or more components were the most effective for treating PTSD symptoms, and these approaches were promising for the management of disturbances of self-organisation. What do these findings mean? Existing evidence-based trauma-focused psychological treatments can be effectively used as first-line therapy for PTSD and mental health comorbidities in people exposed to complex trauma. Because phasing of treatment was categorised as a constituent part of multicomponent interventions, there is a case to move beyond binary distinctions of phase-based versus non-phase-based interventions, which has hampered progress in PTSD research. Future studies could test the most effective means to deliver patient-centred and multicomponent interventions for people exposed to complex trauma, especially in those with higher levels of mental health comorbidity.

\ud The ICD-11 reconceptualized Posttraumatic Stress Disorder (PTSD) as a narrowly defined fear-based disorder, and introduced Complex PTSD (CPTSD) as a new diagnosis comprised of PTSD symptoms and symptoms of ‘Disturbances in Self-Organization’ (DSO) that are more reflective of general dysphoria. Previous research suggests that PTSD symptoms mediate the association between childhood trauma and physical health problems, including cardiovascular disease. No study has yet assessed how posttraumatic stress symptoms, as outlined in the ICD-11, influence the association between childhood trauma and somatic problems in adulthood.\ud \ud Objective\ud This cross-sectional descriptive study examined whether PTSD and DSO symptoms mediated the associations between childhood physical and sexual abuse and childhood emotional abuse and neglect and somatic problems and cardiovascular diseases (CVD) load in adulthood.\ud \ud Methods\ud General adult population samples from Ireland (N = 1020) and the United Kingdom (N = 1051) completed self-report questionnaires online.\ud \ud Results\ud Structural equation modelling results indicated that PTSD and DSO symptoms fully mediated the association between both forms of childhood trauma and somatic problems, and that PTSD symptoms but not DSO symptoms fully mediated the association between childhood trauma and CVD load.\ud \ud Conclusion\ud Psychological interventions that effectively treat CPTSD symptoms may have the added benefit of reducing risk of physical health problems.

Aim\ud The prevalence of anxiety, depression and post‐traumatic stress disorder (PTSD) in the general population has been estimated to be 5.9, 3.3 and 4.4% respectively. The aim of this study was to determine whether psychological problems are more prevalent following colorectal surgery.\ud Method\ud Patients who had undergone colorectal resection in a 2‐year period across 4 centres were asked to complete validated screening questionnaires for anxiety, depression and PTSD (GAD‐7, PHQ‐9, PCL‐5) 12‐48 months after surgery. Risk factors were identified using multiple linear regression analysis.\ud Results\ud After excluding those who had died or received palliative diagnoses, questionnaires were sent to 1150 patients. 371 responded (32.3% response rate); median age 67 (20‐99) years, 51% were male. 58% of patients underwent surgery for cancer, 23% had emergency surgery. 28% of patients screened positive for at least one psychological condition, with 20% screening positive for anxiety, 22% for depression and 14% for PTSD. Patients who were younger, female, had surgery as an emergency, for benign conditions, had stomas and critical care stay were more likely to have poorer psychological outcomes. Multiple linear regression found that only younger age (p=0.000) and female gender (p=0.048) were significant risk factors.\ud Conclusion\ud The prevalence of anxiety, depression and PTSD appears to be high in patients who have undergone colorectal surgery. Younger patients and women are particularly at risk. Further work is needed to determine how best to prevent, detect and treat people with adverse psychological outcomes following colorectal surgery.

Objective To explore the potential efficacy of multi-modular motion-assisted memory desensitization and reprocessing (3MDR) in British military veterans with treatment-resistant service-related PTSD. Methods Exploratory single-blind, randomized, parallel arm, cross-over controlled trial with nested process evaluation to assess fidelity, adherence and factors that influence outcome. Results A total of 42 participants (all male) were randomized with 83% retention at 12 weeks and 86% at 26 weeks. The difference in mean Clinician-Administered PTSD Scale for DSM-5 scores between the immediate and delayed 3MDR arms was -9.38 (95% CI -17.33 to -1.44,P = 0.021) at 12 weeks and -3.59 (-14.39 to 7.20,P = 0.513) at 26 weeks when both groups had received 3MDR. The likely effect size of 3MDR was found to be 0.65. Improvements were maintained at 26-week follow-up. 3MDR was found to be acceptable to most, but not all, participants. Several factors that may impact efficacy and acceptability of 3MDR were identified. Conclusion 3MDR is a promising new intervention for treatment-resistant PTSD with emerging evidence of effect.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the efficacy and acceptability of early pharmacological interventions in adults experiencing acute traumatic stress symptoms, and to generate clinically useful rankings of pharmacological interventions according to their efficacy and acceptability by performing a network meta‐analysis.

SummaryThere is strong research evidence to support the pharmacological treatment of post-traumatic stress disorder (PTSD) as a second line to trauma-focused psychological interventions. Fluoxetine, paroxetine, sertraline and venlafaxine are the best-evidenced drugs, with lower-level evidence for other medications. It is important that prescribing for PTSD is evidence-based.

Background: Psychological therapies are the recommended first-line treatment for posttraumatic\ud stress disorder (PTSD). Previous systematic reviews have grouped theoretically\ud similar interventions to determine differences between broadly distinct approaches.\ud Consequently, we know little regarding the relative efficacy of the specific manualised\ud therapies commonly applied to the treatment of PTSD.\ud Objective: To determine the effect sizes of manualised therapies for PTSD.\ud Methods: We undertook a systematic review following Cochrane Collaboration guidelines. A\ud pre determined definition of clinical importance was applied to the results and the quality of\ud evidence was appraised using the Grading of Recommendations, Assessment, Development\ud and Evaluations (GRADE) approach.\ud Results: 114 randomised controlled trials (RCTs) of 8171 participants were included. There\ud was robust evidence that the therapies broadly defined as CBT with a trauma focus (CBT-T),\ud as well as Eye Movement Desensitisation and Reprocessing (EMDR), had a clinically important\ud effect. The manualised CBT-Ts with the strongest evidence of effect were Cognitive\ud Processing Therapy (CPT); Cognitive Therapy (CT); and Prolonged Exposure (PE). There was\ud also some evidence supporting CBT without a trauma focus; group CBT with a trauma focus;\ud guided internet-based CBT; and Present Centred Therapy (PCT). There was emerging\ud evidence for a number of other therapies.\ud Conclusions: A recent increase in RCTs of psychological therapies for PTSD, results in a more\ud confident recommendation of CBT-T and EMDR as the first-line treatments. Among the CBTTs\ud considered by the review CPT, CT and PE should be the treatments of choice. The findings\ud should guide evidence informed shared decision making between patient and clinician.

Objective\ud To determine whether Internet‐delivered cognitive behavioural therapy (i‐CBT) is an effective treatment for those who meet diagnostic criteria for post‐traumatic stress disorder (PTSD).\ud \ud Method\ud A systematic review was undertaken according to Cochrane Collaboration Guidelines. The primary outcome measures were reduction in PTSD symptoms and drop‐out. Categorical outcomes were meta‐analysed as risk ratios (RRs) and continuous outcomes as mean differences (MDs) or standardised mean differences (SMDs).\ud \ud Results\ud Ten studies with 720 participants were included. Evidence showed that i‐CBT may be associated with a clinically important reduction in post‐treatment PTSD symptoms compared with wait list (SMD −0.60, 95% confidence interval −0.97 to −0.24; N = 560); however, only three studies reported follow‐up data, and there was no evidence to support the maintenance of symptom improvement at follow‐up of 3–6 months. There was no evidence of a difference in PTSD symptoms between i‐CBT and Internet‐delivered non‐CBT post‐treatment. There was evidence of greater treatment effect from trauma‐focused i‐CBT than i‐CBT without a trauma focus, as well as evidence that treatment effect was increased by the provision of guidance.\ud \ud Conclusions\ud While the review found some beneficial effects of i‐CBT for PTSD post‐treatment, the quality of the evidence was very low because of the small number of included trials and there was insufficient evidence to support the maintenance of improvement at follow‐up of 3–6 months. Further work is required to establish non‐inferiority to current first‐line interventions; to determine long‐term efficacy; to explore mechanisms of effect; and to establish optimal levels of guidance.

Post-traumatic stress disorder (PTSD) is a common mental disorder associated with significant distress and reduced functioning. Its occurrence after a severe traumatic event and association with characteristic neurobiological changes make PTSD a good candidate for pharmacological prevention and early treatment. The primary aim for this systematic review and meta-analysis was to assess whether pharmacological interventions when compared to placebo, or other pharmacological/psychosocial interventions resulted in a clinically significant reduction or prevention of symptoms, improved functioning or quality of life, presence of disorder, or adverse effects. A systematic search was undertaken to identify RCTs, which used early pharmacotherapy (within three months of a traumatic event) to prevent and treat PTSD and acute stress disorder (ASD) in children and adults. Using Cochrane Collaboration methodology, RCTs were identified and rated for risk of bias. Available data was pooled to calculate risk ratios (RR) for PTSD prevalence and standardised mean differences (SMD) for PTSD severity. 19 RCTs met the inclusion criteria; 16 studies with adult participants and three with children. The methodological quality of most trials was low. Only hydrocortisone in adults was found to be superior to placebo (3 studies, n = 88, RR: 0.21 (CI 0.05 to 0.89)) although this was in populations with severe physical illness, raising concerns about generalisability. No significant effects were found for the other pharmacotherapies investigated (propranolol, oxytocin, gabapentin, fish oil (1470 mg DHA/147 mg EPA), fish oil (224 mg DHA/22.4 mg EPA), dexamethasone, escitalopram, imipramine and chloral hydrate). Hydrocortisone shows the most promise, of pharmacotherapies subjected to RCTs, as an emerging intervention in the prevention of PTSD within three months after trauma and should be a target for further investigation. The limited evidence for hydrocortisone and its adverse effects mean it cannot be recommended for routine use, but, it could be considered as a preventative intervention for people with severe physical illness or injury, shortly after a traumatic event, as long as there are no contraindications. More research is needed using larger, high quality RCTs to establish the most efficacious use of hydrocortisone in different populations and optimal dosing, dosing window and route. There is currently a lack of evidence to suggest that other pharmacological agents are likely to be effective.

Background: Post-traumatic stress disorder (PTSD) is a common and debilitating disorder which has a significant impact on the lives of sufferers. A number of early psychological interventions have been developed to try to prevent chronic difficulties. Objective: The objective of this study was to establish the current evidence for the effectiveness of multiple session early psychological interventions aimed at preventing or treating traumatic stress symptoms beginning within three months of trauma exposure. Methods: Randomized controlled trials of early multiple session psychological interventions aimed at preventing or reducing traumatic stress symptoms of individuals exposed to a traumatic event, fulfiling trauma criteria for an ICD or DSM diagnosis of PTSD were identified through a search of the Cochrane Common Mental Disorders Group Clinical Trials Registers database, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO and PILOTS. Two authors independently extracted study details and data and completed risk of bias assessments. Analyses were undertaken using Review Manager software. Quality of findings were rated according to ‘Grades of Recommendation, Assessment, Development, and Evaluation’ (GRADE) and appraised for clinical importance. Results: Sixty-one studies evaluating a variety of interventions were identified. For individuals exposed to a trauma who were not pre-screened for traumatic stress symptoms there were no clinically important differences between any intervention and usual care. For individuals reporting traumatic stress symptoms we found clinically important evidence of benefits for trauma-focused cognitive-behavioural therapy (CBT-T), cognitive therapy without exposure and eye movement desensitization and reprocessing (EMDR). Differences were greatest for those diagnosed with acute stress disorder (ASD) and PTSD. Conclusions: There is evidence for the effectiveness of several early psychological interventions for individuals with traumatic stress symptoms following trauma exposure, especially for those meeting the diagnostic threshold for ASD or PTSD. Evidence is strongest for trauma-focused CBT. • We found no clinically important evidence for the benefit of early intervention offered to all individuals exposed to a traumatic event, regardless of symptomatology.• There was evidence of a clinically important effect for trauma-focused CBT (CBT-T), brief EMDR and cognitive therapy without exposure.• Evidence was strongest for CBT-T.

Objective To assess whether severe psychiatric reactions to trauma and other adversities are associated with subsequent risk of life threatening infections. Design Population and sibling matched cohort study. Setting Swedish population. Participants 144 919 individuals with stress related disorders (post-traumatic stress disorder (PTSD), acute stress reaction, adjustment disorder, and other stress reactions) identified from 1987 to 2013 compared with 184 612 full siblings of individuals with a diagnosed stress related disorder and 1 449 190 matched individuals without such a diagnosis from the general population. Main outcome measures A first inpatient or outpatient visit with a primary diagnosis of severe infections with high mortality rates (ie, sepsis, endocarditis, and meningitis or other central nervous system infections) from the Swedish National Patient Register, and deaths from these infections or infections of any origin from the Cause of Death Register. After controlling for multiple confounders, Cox models were used to estimate hazard ratios of these life threatening infections. Results The average age at diagnosis of a stress related disorder was 37 years (55 541, 38.3% men). During a mean follow-up of eight years, the incidence of life threatening infections per 1000 person years was 2.9 in individuals with a stress related disorder, 1.7 in siblings without a diagnosis, and 1.3 in matched individuals without a diagnosis. Compared with full siblings without a diagnosis of a stress related disorder, individuals with such a diagnosis were at increased risk of life threatening infections (hazard ratio for any stress related disorder was 1.47 (95% confidence intervals1.37 to 1.58) and for PTSD was 1.92 (1.46 to 2.52)). Corresponding estimates in the population based analysis were similar (1.58 (1.51 to 1.65) for any stress related disorder, P=0.09 for difference between sibling and population based comparison, and 1.95 (1.66 to 2.28) for PTSD, P=0.92 for difference). Stress related disorders were associated with all studied life threatening infections, with the highest relative risk observed for meningitis (sibling based analysis 1.63 (1.23 to 2.16)) and endocarditis (1.57 (1.08 to 2.30)). Younger age at diagnosis of a stress related disorder and the presence of psychiatric comorbidity, especially substance use disorders, were associated with higher hazard ratios, whereas use of selective serotonin reuptake inhibitors in the first year after diagnosis of a stress related disorder was associated with attenuated hazard ratios. Conclusion In the Swedish population, stress related disorders were associated with a subsequent risk of life threatening infections, after controlling for familial background and physical or psychiatric comorbidities.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:\ud\udTo assess the efficacy and acceptability of pharmacological interventions for preventing post‐traumatic stress disorder (PTSD) in adults exposed to a traumatic event and to generate a clinically useful ranking of pharmacological interventions according to their efficacy and acceptability by performing a network meta‐analysis.

BackgroundThe 11th revision to the WHO International Classification of Diseases (ICD-11) identified complex post-traumatic stress disorder (CPTSD) as a new condition. There is a pressing need to identify effective CPTSD interventions.MethodsWe conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of psychological interventions for post-traumatic stress disorder (PTSD), where participants were likely to have clinically significant baseline levels of one or more CPTSD symptom clusters (affect dysregulation, negative self-concept and/or disturbed relationships). We searched MEDLINE, PsycINFO, EMBASE and PILOTS databases (January 2018), and examined study and outcome quality.ResultsFifty-one RCTs met inclusion criteria. Cognitive behavioural therapy (CBT), exposure alone (EA) and eye movement desensitisation and reprocessing (EMDR) were superior to usual care for PTSD symptoms, with effects ranging from g = −0.90 (CBT; k = 27, 95% CI −1.11 to −0.68; moderate quality) to g = −1.26 (EMDR; k = 4, 95% CI −2.01 to −0.51; low quality). CBT and EA each had moderate–large or large effects on negative self-concept, but only one trial of EMDR provided useable data. CBT, EA and EMDR each had moderate or moderate–large effects on disturbed relationships. Few RCTs reported affect dysregulation data. The benefits of all interventions were smaller when compared with non-specific interventions (e.g. befriending). Multivariate meta-regression suggested childhood-onset trauma was associated with a poorer outcome.ConclusionsThe development of effective interventions for CPTSD can build upon the success of PTSD interventions. Further research should assess the benefits of flexibility in intervention selection, sequencing and delivery, based on clinical need and patient preferences.

Background\ud Although a large number of clinical trials on interventions demonstrating efficacy (or lack thereof) are conducted annually, much of this evidence is not accessible to scientists and clinicians.\ud \ud Objectives\ud We aimed to determine the publication rate of posttraumatic stress disorder (PTSD) trials that have been registered in clinical trial registries, and the factors associated with publication.\ud \ud Methods\ud Trials, completed on January 15, 2015, were identified via the US National Institutes of Health clinical trials registry, the European Union Clinical Trials Register and the WHO International Clinical Trials Registry Platform. A systematic search for publications (published by the end of March 2018) related to each of the registered trials were then performed.\ud \ud Results\ud Four hundred and thirty-eight of 1982 potentially eligible trials were included. Only 34% of interventional trials were registered prior to initiation, 9% were registered within 2 months of starting and 20% after trial completion. Of the 438 included trials, 72% had generated peer-reviewed publications, while an additional 7% had disseminated results in some other form (such as on the trial database), 26 months after trial completion. Randomisation of a trial was the only factor individually associated with publication, in logistic regression analysis (p

Background: Post-traumatic stress disorder (PTSD) is a major cause of morbidity amongst active duty and ex-serving military personnel. In recent years increasing efforts have been made to develop more effective treatments.\ud\udObjective: To determine which psychological therapies are efficacious in treating active duty and ex-serving military personnel with post-traumatic stress disorder (PTSD).\ud\udMethod: A systematic review was undertaken according to Cochrane Collaboration Guidelines. The primary outcome measure was reduction in PTSD symptoms and the secondary outcome dropout.\ud\udResults: Twenty-four studies with 2386 participants were included. Evidence demonstrated that CBT with a trauma focus (CBT-TF) was associated with the largest evidence of effect when compared to waitlist/usual care in reducing PTSD symptoms post treatment (10 studies; n = 524; SMD −1.22, −1.78 to −0.66). Group CBT-TF was less effective when compared to individual CBT-TF at reducing PTSD symptoms post treatment (1 study; n = 268; SMD −0.35, −0.11 to −0.59). Eye Movement Desensitization and Reprocessing (EMDR) therapy was not effective when compared to waitlist/usual care at reducing PTSD symptoms post treatment (4 studies; n = 92; SMD −0.83, −1.75 to 0.10). There was evidence of greater dropout from CBT-TF therapies compared to waitlist and Present Centred Therapy. Conclusions: The evidence, albeit limited, supports individual CBT-TF as the first-line psychological treatment of PTSD in active duty and ex-serving personnel. There is evidence for Group CBT-TF, but this is not as strong as for individual CBT-TF. EMDR cannot be recommended as a first line therapy at present and urgently requires further evaluation. Lower effect sizes than for other populations with PTSD and high levels of drop-out suggest that CBT-TF in its current formats is not optimally acceptable and further research is required to develop and evaluate more effective treatments for PTSD and complex PTSD in active duty and ex-serving military personnel.

Background: Internet-delivered Cognitive Behavioural Therapy (i-CBT) offers potential as an alternative, accessible, clinically and cost-effective treatment for post-traumatic stress disorder (PTSD), but little is known about its acceptability.\ud \ud Objective: To review the available evidence to understand the acceptability of i-CBT for PTSD.\ud \ud Method: We undertook a mixed-methods systematic review according to Cochrane Collaboration Guidelines, of randomised controlled trials (RCTs) of i-CBT for adults with PTSD. We examined included studies for measures of acceptability, and possible proxy indicators of acceptability, including dropout rates, which were meta-analysed as risk ratios (RRs).\ud \ud Results: Ten studies with 720 participants were included. We found i-CBT to be acceptable according to specific acceptability measures, and suggestions for acceptability according to some proxy measures of i-CBT programme usage. There was, however, evidence of greater dropout from i-CBT than waitlist (RR 1.39, CI 1.03–1.88; 8 studies; participants = 585) and no evidence of a difference in dropout between i-CBT and i-non-CBT (RR 2.14, CI 0.97–4.73; participants = 132; 2 studies).\ud \ud Conclusion: i-CBT appears a potentially acceptable intervention for adults with PTSD. We identified clinical and research questions, including the status of proxy indicators, and call for standardised, consistent treatment acceptability measurement.

Antecedentes: El apoyo social percibido (ASP) es uno de los factores de riesgo más importantes para el inicio y mantención de los síntomas del trastorno de estrés postraumático (TEPT), sin embargo se desconoce la relación entre ASP y TEPT Complejo (TEPTC). Actualmente faltan tratamientos basados en la evidencia para TEPTC, a pesar de la importancia creciente dada la reciente publicación de la CIE-11, que permite el diagnóstico formal de TEPTC.Objetivo: Esta investigación pretende desarrollar una comprensión de la relación entre el ASP y TEPTC con el fin de informar la existencia de tratamientos nuevos y ya existentes.Método: Se realizó un estudio transversal con 246 individuos reclutados de una cohorte del Centro Nacional de Salud Mental (NCMH por sus siglas en inglés. Las medidas de ASP y TEPT/TEPTC fueron realizadas con esta muestra clínica y se condujo una regresión lineal y logística para evaluar la asociación entre ASP y síntomas de TEPT de los grupos del DSM-5 y CIE-11, y explorar la utilidad predictiva de cualquier asociación de ASP en la probabilidad de presentación de un TEPTC.Resultados: Se encontró que individuos con una presentación de TEPTC tendían a mostrar niveles más bajos de ASP, comparados con individuos que no se presentaban con TEPTC, y ASP más bajos tenían una asociación única estadísticamente significativa con la probabilidad de presentarse con TEPTC.Conclusiones: La intervención que pretende mejorar el ASP podría ser particularmente de ayuda para algunos individuos con TEPTC, especialmente aquellos con alteraciones en las relaciones, y existe oportunidad de desarrollar entrenamiento en destrezas con una aproximación basado en fases para tratar aquellos factores claves relacionados con ASP.

BackgroundPost-Traumatic Stress Disorder (PTSD) is a mental health disorder characterised by symptoms of re-experiencing, avoidance and hyperarousal that may develop after exposure to a traumatising event. The prevalence of PTSD within the refugee population is ten times higher than in the general population. This audit was carried out in Cardiff Health Access Practice (CHAP) which is the main provider of primary health care for refugees and asylum seekers who are sent to Cardiff. The main objective of this audit was to evaluate current PTSD prescribing practice for patients presenting to Cardiff Health Access Practice (CHAP) against a pharmacological prescribing algorithm which has been developed for the Cardiff and Vale Traumatic Stress Service based on NICE and International Society for Traumatic Stress Studies guidelinesMethodA retrospective audit of patients with PTSD seen in the last 12 months at CHAP. Data were collected from patient notes and information on age, sex, trauma, comorbidities and medication dose was collated and analysed using SPSS statistics.Result130 patients with PTSD were identified and their medications assessed for the audit. The mean age of these patients was 33 years and there was a 1.5:1 male to female ratio. Of the 130 patients only 10 were initiated on a first line medication, 117 were started on a fourth line medication. No patients were prescribed either the second- or third-line medications.ConclusionThe low rates of compliance with the All Wales Pharmacological PTSD pharmacological prescribing algorithm are disappointing although not unexpected as it has yet to be fully introduced to the service. Following discussion of the results and teaching about the algorithm with clinicians in Cardiff Health Access Practice rates of evidence-based prescribing should improve. This audit focuses on a patient group (refugee and asylum seekers) which has been identified as a priority group by the Welsh Government. Through further implementation of this algorithm there should be improved evidence-based prescribing and continuity of care for refugees

BACKGROUND:\ud \ud Following the recently published 11th version of the WHO International Classification of Diseases (ICD-11), we sought to examine the risk factors and comorbidities associated with posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD).\ud METHOD:\ud \ud Cross-sectional and retrospective design. The sample consisted of 1,051 trauma-exposed participants from a nationally representative panel of the UK adult population.\ud RESULTS:\ud \ud A total of 5.3% (95% confidence interval [CI] = 4.0-6.7%) met the diagnostic criteria for PTSD and 12.9% (95% CI = 10.9-15.0%) for CPTSD. Diagnosis of PTSD was independently associated with being female, being in a relationship, and the recency of traumatic exposure. CPTSD was independently associated with younger age, interpersonal trauma in childhood, and interpersonal trauma in adulthood. Growing up in an urban environment was associated with the diagnosis of PTSD and CPTSD. High rates of physical and mental health comorbidity were observed for PTSD and CPTSD. Those with CPTSD were more likely to endorse symptoms reflecting major depressive disorder (odds ratio [OR] = 21.85, 95 CI = 12.51-38.04) and generalized anxiety disorder (OR = 24.63, 95 CI = 14.77-41.07). Presence of PTSD (OR = 3.13, 95 CI = 1.81-5.41) and CPTSD (OR = 3.43, 95 CI = 2.37-4.70) increased the likelihood of suicidality by more than three times. Nearly half the participants with PTSD and CPTSD reported the presence of a chronic illness.\ud CONCLUSIONS:\ud \ud CPTSD is a more common, comorbid, debilitating condition compared to PTSD. Further research is now required to identify effective interventions for its treatment.

The primary aim of this study was to provide an assessment of the current prevalence rates of International Classification of Diseases (11th rev.) posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) among the adult population of the United States and to identify characteristics and correlates associated with each disorder. A total of 7.2% of the sample met criteria for either PTSD or CPTSD, and the prevalence rates were 3.4% for PTSD and 3.8% for CPTSD. Women were more likely than men to meet criteria for both PTSD and CPTSD. Cumulative adulthood trauma was associated with both PTSD and CPTSD; however, cumulative childhood trauma was more strongly associated with CPTSD than PTSD. Among traumatic stressors occurring in childhood, sexual and physical abuse by caregivers were identified as events associated with risk for CPTSD, whereas sexual assault by noncaregivers and abduction were risk factors for PTSD. Adverse childhood events were associated with both PTSD and CPTSD, and equally so. Individuals with CPTSD reported substantially higher psychiatric burden and lower levels of psychological well-being compared to those with PTSD and those with neither diagnosis.Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) El Trastorno de Estrés Postraumático y el Trastorno de Estrés Postraumático Complejo de la CIE-11 en los Estados Unidos: Un Estudio Basado en la Población TEPT Y TEPT COMPLEJO EN LOS ESTADOS UNIDOS El objetivo principal de este estudio fue proporcionar una evaluación de las tasas de prevalencia actuales del trastorno de estrés postraumático (TEPT) y el TEPT complejo (TEPT-C) según la Clasificación Internacional de Enfermedades (11ª rev.) en la población adulta de los Estados Unidos y para identificar las características y los correlatos asociados con cada trastorno. Un total de 7.2% de la muestra cumplió con los criterios ya sea para TEPT o TEPT-C, y las tasas de prevalencia fueron 3.4% para TEPT y 3.8% para TEPT-C. Las mujeres fueron más propensas que los hombres a cumplir los criterios tanto para el TEPT como para el TEPT-C. El trauma acumulativo en la edad adulta se asoció tanto con el TEPT como con el TEPT-C; sin embargo, el trauma infantil acumulativo se asoció más fuertemente con el TEPT-C que con el TEPT. Entre los estresores traumáticos que ocurren en la infancia, el abuso sexual y físico por parte de los cuidadores se identificaron como los eventos asociados con riesgo de TEPT-C, mientras que la agresión sexual por parte de los no cuidadores y el secuestro fueron factores de riesgo para el TEPT. Los eventos adversos en la infancia se asociaron tanto con el TEPT como con el TEPT-C, de forma equivalente. Las personas con TEPT-C informaron sustancialmente mayor carga psiquiátrica y menores niveles de bienestar psicológico en comparación con aquellos con TEPT y aquellos sin diagnóstico.Traditional and Simplified Chinese Abstracts by the Asian Society for Traumatic Stress Studies (AsianSTSS) 簡體及繁體中文撮要由亞洲創傷心理研究學會翻譯 ICD-11 PTSD and Complex PTSD in the United States: A population-based study Traditional Chinese 標題: 美國根據ICD-11的準則確診的PTSD與CPTSD個案:人口研究 撮要: 本研究的主要目的為評估目前的美國成年人當中, 根據國際疾病與相關健康問題統計分類第十一版(ICD-11)的準則而確診患創傷後壓力症(PTSD)和複雜型創傷後壓力症(CPTSD)的患病率, 並辨識兩種病症的特徵和關連因素。共有7.2%的樣本符合患PTSD或CPTSD的準則, 而PTSD的患病率為3.4%, CPTSD的患病率為3.8%。女性比男性有較大機會同時符合患PTSD及CPTSD的準則。累積的成年創傷跟PTSD及CPTSD都有關, 可是累積的童年創傷跟CPTSD的關連比跟PTSD的關連更強。在童年的創傷壓力源當中, 照料者施加的性虐和體虐跟有風險患CPTSD相關, 而非照料者作出性侵犯及綁架乃患PTSD的風險因素。童年的負面事件跟PTSD及CPTSD都有關, 兩者的關連同等。CPTSD患者相比起PTSD患者或無患兩者的人士, 有顯著較大的精神負擔及較低水平的心理健康。 Simplified Chinese 标题: 美国根据ICD-11的准则确诊的PTSD与CPTSD个案:人口研究 撮要: 本研究的主要目的为评估目前的美国成年人当中, 根据国际疾病与相关健康问题统计分类第十一版(ICD-11)的准则而确诊患创伤后压力症(PTSD)和复杂型创伤后压力症(CPTSD)的患病率, 并辨识两种病症的特征和关连因素。共有7.2%的样本符合患PTSD或CPTSD的准则, 而PTSD的患病率为3.4%, CPTSD的患病率为3.8%。女性比男性有较大机会同时符合患PTSD及CPTSD的准则。累积的成年创伤跟PTSD及CPTSD都有关, 可是累积的童年创伤跟CPTSD的关连比跟PTSD的关连更强。在童年的创伤压力源当中, 照料者施加的性虐和体虐跟有风险患CPTSD相关, 而非照料者作出性侵犯及绑架乃患PTSD的风险因素。童年的负面事件跟PTSD及CPTSD都有关, 两者的关连同等。CPTSD患者相比起PTSD患者或无患两者的人士, 有显著较大的精神负担及较低水平的心理健康。.

Identification of comorbid post-traumatic stress disorder (PTSD) in patients with other serious mental illness is of substantial importance given that this is associated with poorer clinical outcomes of these disorders,1–4 and that PTSD is a treatable disorder.5 Some studies suggest that a large proportion of patients in secondary-care mental health services with other (non-PTSD) primary diagnoses meet criteria for PTSD on screening, and that there is usually no record of PTSD in the patient’s clinical records.6–9 If these estimates of undetected PTSD are accurate this raises a serious concern that PTSD is not adequately identified through routine clinical care pathways. Other studies, however, report much lower frequencies of undetected PTSD.10–12 Reasons for variation in estimates of PTSD across studies could include differences in the characteristics of the people in the study (such as gender, primary diagnosis) or of the study methodology (such as measurement or selection bias). An accurate estimate of the frequency of undetected PTSD in secondary care, and an understanding of factors associated with variation in frequency is required to determine if, and how, services should respond. In this study, we systematically review the literature to determine whether undetected PTSD is present at a prevalence that would reflect substantial clinical importance within secondary-care mental health services. For the purpose of this study we define ‘substantial clinical importance’ as presence of undetected PTSD in 10% or more of patients in secondary care, an arbitrary value but one that we believe most service providers would agree merits clinical concern. Furthermore, we also aim to determine the extent to which variation in reported estimates might be because of sample characteristics or methodological biases. To our knowledge there have not been any previous systematic reviews addressing these aims.

Background Facial scarring can have a dramatic effect on a patient's psychological health and wellbeing and present unique management challenges. This patient population remains poorly characterised in the contemporary literature. Aims To evaluate the prevalence of, and risk factors associated with affective disorders in adult patients with facial scars. Methods A systematic review was conducted using a protocol registered with PROSPERO and in line with the PRISMA statement. A comprehensive search of the literature was conducted using PubMed, MEDLINE, EMBASE, PSYCHInfo and The Cochrane Library. Results Twenty one studies were included, with a total of 2,394 participants. Using a random effects model, the weighted pooled prevalence of anxiety was 26.1% (95% CI 17.9%-36.3%) and the weighted pooled prevalence of depression was 21.4% (95% CI 15.4%-29.0%). Studies identified female gender, past psychiatric history and violent causation as factors associated with anxiety and depression. Limitations Included studies were limited to those published in peer reviewed journals. Longitudinal trends in both anxiety and depression were limited by a short duration of follow up. Conclusions There is a high and persistent burden of affective disorders in patients with facial scars. Additional research is required to further characterise this population and develop effective management strategies.

There is good evidence that trauma-focused therapies for Post-Traumatic Stress Disorder are effective. However, they are not always feasible to deliver due a shortage of trained therapists and demands on the patient. An online trauma-focused Guided Self-Help (GSH) programme which could overcome these barriers has shown promise in a pilot study. This study will be the first to evaluate GSH against standard face-to-face therapy to assess its suitability for use in the NHS. The study is a large-scale multi-centre pragmatic randomised controlled non-inferiority trial, with assessors masked to treatment allocation. One hundred and ninety-two participants will be randomly allocated to receive either face-to-face trauma-focused cognitive behaviour therapy (TFCBT) or trauma-focused online guided self-help (GSH). The primary outcome will be the severity of symptoms of PTSD over the previous week as measured by the Clinician Administered PTSD Scale for DSM5 (CAPS-5) at 16 weeks post-randomisation. Secondary outcome measures include PTSD symptoms over the previous month as measured by the CAPS-5 at 52 weeks plus the Impact of Event Scale – revised (IES-R), Work and Social Adjustment Scale (WSAS), Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder-7 (GAD-7), Alcohol Use Disorders Test (AUDIT-O), Multidimensional Scale for Perceived Social Support (MSPSS), short Post-Traumatic Cognitions Inventory (PTCI), Insomnia Severity Index (ISI) and General Self Efficacy Scale (GSES) measured at 16 and 52 weeks post-randomisation. Changes in health-related quality of life will be measured by the EQ-5D and the level of healthcare resource utilisation for health economic analysis will be determined by an amended version of the Client Socio-Demographic and Service Receipt Inventory European Version. The Client Satisfaction Questionnaire (CSQ) will be collected at 16 weeks post-randomisation to evaluate treatment satisfaction. This study will be the first to compare online GSH with usual face-to-face therapy for PTSD. The strengths are that it will test a rigorously developed intervention in a real world setting to inform NHS commissioning. The potential challenges of delivering such a pragmatic study may include participant recruitment, retention and adherence, therapist retention, and fidelity of intervention delivery. ISRCTN13697710 registered on 20/12/2016.

Objective\ud \ud Recently, the American Psychiatric Association (DSM-5) and the World Health Organization (ICD-11) have both revised their formulation of post-traumatic stress disorder (PTSD). The primary aim of this study was to compare DSM-5 and ICD-11 PTSD prevalence and comorbidity rates, as well as the level of disability associated with each diagnosis.\ud \ud \ud Method\ud \ud This study was based on a representative sample of adult Ukrainian internally displaced persons (IDPs: N = 2203). Post-traumatic stress disorder prevalence was assessed using the PTSD Checklist for DSM-5 and the International Trauma Questionnaire (ICD-11). Anxiety and depression were measured using the Generalized Anxiety Disorder Scale and the Patient Health Questionnaire-Depression. Disability was measured using the WHO Disability Assessment Schedule 2.0.\ud \ud \ud Results\ud \ud The prevalence of DSM-5 PTSD (27.4%) was significantly higher than ICD-11 PTSD (21.0%), and PTSD rates for females were significantly higher using both criteria. ICD-11 PTSD was associated with significantly higher levels of disability and comorbidity.\ud \ud \ud Conclusion\ud \ud The ICD-11 diagnosis of PTSD appears to be particularly well suited to identifying those with clinically relevant levels of disability.

Background: Trauma exposure and posttraumatic stress disorder (PTSD) are common among individuals with a mental disorder, but symptoms often go undetected and untreated. Methods: The aim of this study was to determine the prevalence of PTSD among a large sample of adults with psychiatric diagnoses and to establish factors associated with symptoms going undetected. Participants were 1,946 adults recruited by the National Centre for Mental Health. Structured interviews and validated self-report questionnaires were used to ascertain clinical and demographic information for analysis. Results: The prevalence of participants screening positive for PTSD that had not been detected by clinical services was 13.9% [12.4–15.5%, 95% confidence interval]). Factors associated with undetected PTSD were female gender, younger age of first contact with psychiatric services, and lower household income. Especially, poor rates of detection were observed after traumatic events, such as child abuse and sexual assault. Conclusions: Our findings demonstrate the need for routine assessment of trauma histories and symptoms of PTSD among individuals with anymental disorder.

Background\ud \ud Local and national governments have implemented sector-specific policies to support economic development through innovation, entrepreneurship and knowledge exchange. Supported by the Welsh Government through the European Regional Development Fund, The Life Science Exchange® project was created with the aim to increase interaction between stakeholders, to develop more effective knowledge exchange mechanisms, and to stimulate the formation and maintenance of long-term collaborative relationships within the Welsh life sciences ecosystem. The Life Science Exchange allowed participants to interact with other stakeholder communities (clinical, academic, business, governmental), exchange perspectives and discover new opportunities.\ud \ud \ud Methods\ud \ud Six sub-sector focus groups comprising over 200 senior stakeholders from academia, industry, the Welsh Government and National Health Service were established. Over 18 months, each focus group provided input to inform healthcare innovation policy and knowledge mapping exercises of their respective sub-sectors. Collaborative projects identified during the focus groups and stakeholder engagement were further developed through sandpit events and bespoke support.\ud \ud \ud Results\ud \ud Each sub-sector focus group produced a report outlining the significant strengths and opportunities in their respective areas of focus, made recommendations to overcome any ‘system failures’, and identified the stakeholder groups which needed to take action. A second outcome was a stakeholder-driven knowledge mapping exercise for each area of focus. Finally, the sandpit events and bespoke support resulted in participants generating more than £1.66 million in grant funding and inward investment. This article outlines four separate outcomes from the Life Science Exchange programme.\ud \ud Conclusions\ud \ud The Life Science Exchange process has resulted in a multitude of collaborations, projects, inward investment opportunities and special interest group formations, in addition to securing over ten times its own costs in funding for Wales. The Life Science Exchange model is a simple and straightforward mechanism for a regional or national government to adapt and implement in order to improve innovation, skills, networks and knowledge exchange.

BACKGROUND: Post‐traumatic stress disorder (PTSD) is a debilitating mental health disorder that may develop after exposure to traumatic events. Substance use disorder (SUD) is a behavioural disorder in which the use of one or more substances is associated with heightened levels of distress, clinically significant impairment of functioning, or both. PTSD and SUD frequently occur together. The comorbidity is widely recognised as being difficult to treat and is associated with poorer treatment completion and poorer outcomes than for either condition alone. Several psychological therapies have been developed to treat the comorbidity, however there is no consensus about which therapies are most effective. OBJECTIVES: To determine the efficacy of psychological therapies aimed at treating traumatic stress symptoms, substance misuse symptoms, or both in people with comorbid PTSD and SUD in comparison with control conditions (usual care, waiting‐list conditions, and no treatment) and other psychological therapies. SEARCH METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Group’s Specialised Register (CCDANCTR) all years to 11 March 2015. This register contains relevant randomised controlled trials from the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov, contacted experts, searched bibliographies of included studies, and performed citation searches of identified articles. SELECTION CRITERIA: Randomised controlled trials of individual or group psychological therapies delivered to individuals with PTSD and comorbid substance use, compared with waiting‐list conditions, usual care, or minimal intervention or to other psychological therapies. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included 14 studies with 1506 participants, of which 13 studies were included in the quantitative synthesis. Most studies involved adult populations. Studies were conducted in a variety of settings. We performed four comparisons investigating the effects of psychological therapies with a trauma‐focused component and non‐trauma‐focused interventions against treatment as usual/minimal intervention and other active psychological therapies. Comparisons were stratified for individual‐ or group‐based therapies. All active interventions were based on cognitive behavioural therapy. Our main findings were as follows. Individual‐based psychological therapies with a trauma‐focused component plus adjunctive SUD intervention was more effective than treatment as usual (TAU)/minimal intervention for PTSD severity post‐treatment (standardised mean difference (SMD) ‐0.41; 95% confidence interval (CI) ‐0.72 to ‐0.10; 4 studies; n = 405; very low‐quality evidence) and at 3 to 4 and 5 to 7 months' follow‐up. There was no evidence of an effect for level of drug/alcohol use post‐treatment (SMD ‐0.13; 95% CI ‐0.41 to 0.15; 3 studies; n = 388; very low‐quality evidence), but there was a small effect in favour of individual psychological therapy at 5 to 7 months (SMD ‐0.28; 95% CI ‐0.48 to ‐0.07; 3 studies; n = 388) when compared against TAU. Fewer participants completed trauma‐focused therapy than TAU (risk ratio (RR) 0.78; 95% CI 0.64 to 0.96; 3 studies; n = 316; low‐quality evidence). Individual‐based psychological therapy with a trauma‐focused component did not perform better than psychological therapy for SUD only for PTSD severity (mean difference (MD) ‐3.91; 95% CI ‐19.16 to 11.34; 1 study; n = 46; low‐quality evidence) or drug/alcohol use (MD ‐1.27; 95% CI ‐5.76 to 3.22; 1 study; n = 46; low‐quality evidence). Findings were based on one small study. No effects were observed for rates of therapy completion (RR 1.00; 95% CI 0.74 to 1.36; 1 study; n = 62; low‐quality evidence). Non‐trauma‐focused psychological therapies did not perform better than TAU/minimal intervention for PTSD severity when delivered on an individual (SMD ‐0.22; 95% CI ‐0.83 to 0.39; 1 study; n = 44; low‐quality evidence) or group basis (SMD ‐0.02; 95% CI ‐0.19 to 0.16; 4 studies; n = 513; low‐quality evidence). There were no data on the effects on drug/alcohol use for individual therapy. There was no evidence of an effect on the level of drug/alcohol use for group‐based therapy (SMD ‐0.03; 95% CI ‐0.37 to 0.31; 4 studies; n = 414; very low‐quality evidence). A post‐hoc analysis for full dose of a widely established group therapy called Seeking Safety showed reduced drug/alcohol use post‐treatment (SMD ‐0.67; 95% CI ‐1.14 to ‐0.19; 2 studies; n = 111), but not at subsequent follow‐ups. Data on the number of participants completing therapy were not for individual‐based therapy. No effects were observed for rates of therapy completion for group‐based therapy (RR 1.13; 95% CI 0.88 to 1.45; 2 studies; n = 217; low‐quality evidence). Non‐trauma‐focused psychological therapy did not perform better than psychological therapy for SUD only for PTSD severity (SMD ‐0.26; 95% CI ‐1.29 to 0.77; 2 studies; n = 128; very low‐quality evidence) or drug/alcohol use (SMD 0.22; 95% CI ‐0.13 to 0.57; 2 studies; n = 128; low‐quality evidence). No effects were observed for rates of therapy completion (RR 0.91; 95% CI 0.68 to 1.20; 2 studies; n = 128; very low‐quality evidence). Several studies reported on adverse events. There were no differences between rates of such events in any comparison. We rated several studies as being at 'high' or 'unclear' risk of bias in multiple domains, including for detection bias and attrition bias. AUTHORS' CONCLUSIONS: We assessed the evidence in this review as mostly low to very low quality. Evidence showed that individual trauma‐focused psychological therapy delivered alongside SUD therapy did better than TAU/minimal intervention in reducing PTSD severity post‐treatment and at long‐term follow‐up, but only reduced SUD at long‐term follow‐up. All effects were small, and follow‐up periods were generally quite short. There was evidence that fewer participants receiving trauma‐focused therapy completed treatment. There was very little evidence to support use of non‐trauma‐focused individual‐ or group‐based integrated therapies. Individuals with more severe and complex presentations (e.g. serious mental illness, individuals with cognitive impairment, and suicidal individuals) were excluded from most studies in this review, and so the findings from this review are not generalisable to such individuals. Some studies suffered from significant methodological problems and some were underpowered, limiting the conclusions that can be drawn. Further research is needed in this area.

INTRODUCTION: Previous literature has shown that multifaceted, interactive interventions may be the most effective way to train health and social care professionals. A Train-the-Trainer (TTT) model could incorporate all these components. We conducted a systematic review to determine the overall effectiveness and optimal delivery of TTT programs. METHODS: We searched 15 databases. Reference lists and online resources were also screened. Studies with an objective follow-up measure collected over 1 week after the intervention were included. The intervention had to be based on a TTT model for health and social care professionals. RESULTS: Eighteen studies met the inclusion criteria. TTT interventions varied greatly, ranging from didactic presentations to group discussions and role-plays. The heterogeneity of the studies and limited data prevented meta-analysis. A narrative review found that the TTT programs in 13 studies helped to increase knowledge, improve clinical behavior, or produce better patient outcomes. One study showed no effect. Three studies showed possible effect and one study showed that a CD-ROM training method was more effective than a TTT training method in improving participants' knowledge. Ratings of the studies' methodologies suggested moderate risk of bias, which limits interpretation of the results. DISCUSSION: There is evidence that using a blended learning approach to deliver TTT programs--combining different techniques such as interactive, multifaceted methods and accompanying learning materials--can help to effectively disseminate and implement guidelines and curricula to health and social care professionals. However, further research is needed to determine the optimum "blend" of techniques.

Aims and methodThe effectiveness of official support provided following a disaster has not been fully evaluated. This study aimed to ascertain whether there was an association between perceived support shortly after the 2004 Indian Ocean tsunami and later mental health symptoms in those affected, and to explore the factors associated with this. A survey, semi-structured interviews and focus group were used to explore the experiences and perceptions of 116 individuals severely affected by the tsunami.ResultsAgency or official support was perceived as poor overall. Perceived ineffectiveness of support available within a few days after the tsunami was associated with increased symptoms of post-traumatic stress disorder 15–19 months later. The strongest themes that emerged from our study were that support provided in a humane manner was perceived as effective and that uncoordinated support, poor communication and limited accessibility to support and information were perceived as ineffective.Clinical implicationsImproved planning of coordinated, flexible, multi-agency responses to traumatic events before they occur is required.

Authors' reply to: Did you add the same study twice in the meta-analysis? by Andrea Cipriani (DOI: 10.1192/bjp.207.2.177). Tol et al provide an explanation involving their use of a preprint report that was later published. A revised meta-analysis table and figure are provided. With the exception of a small improvement in the significance of the drug sertraline effectiveness as a treatment for PTSD, the double report inclusion did not affect the results. Language: en

There is a lack of evidence to manage veterans with service-related mental health problems. This research aimed to develop an optimally effective, feasible, and acceptable integrated care pathway (ICP).A prototype ICP was developed through an initial modeling phase. Systematic reviews informed a portfolio of information for key stakeholders to discuss in a series of focus groups and semistructured interviews. They included 16 mental health professionals with expertise in the fields of mental health provision for military personnel, and 6 veterans with a history of mental illness. Data were analyzed through Inductive Thematic Analysis and used to inform the content, delivery, and guidance of an ICP. The prototype was piloted with 20 veterans in two pilot studies and refined on the basis of their quantitative and qualitative feedback.The final ICP was agreed with additional guidance notes. It included three pathways covering referral, intervention, and management of veterans. Qualitative and quantitative results supported its efficacy in terms of reducing mental health symptoms and its acceptability to veterans.A specific veteran ICP shows promise as an effective and acceptable way of treating veterans with service related mental health problems.

Dissemination of effective early interventions following trauma is necessary to ensure the provision of the best possible care in a timely manner. To achieve this, agreement from all key stakeholders is required regarding the messages to be disseminated and the means of dissemination. This article is based on a National Institute of Mental Health sponsored symposium on the dissemination of early interventions at the 21st annual meeting of the International Society for Traumatic Stress Studies in Toronto in 2005. The current knowledge base regarding the effectiveness and dissemination of early interventions (defined here as those that are begun within the first 3 months after exposure) following trauma for children, adolescents, and adults is considered.