Effects of treatment, choice, and preference on health-related quality-of-life outcomes in patients with posttraumatic stress disorder (PTSD)

Effects of a general practitioner-led brief narrative exposure intervention on symptoms of post-traumatic stress disorder after intensive care (PICTURE): multicentre, observer blind, randomised controlled trial

OBJECTIVE

To determine the effect of a novel brief general practitioner (GP)-led narrative exposure intervention on post-traumatic stress disorder (PTSD) symptoms after intensive care.

DESIGN

Multicentre, observer blind, randomised controlled trial (PICTURE).

SETTING

Primary care in 319 general practices across Germany.

PARTICIPANTS

319 adults (18-85 years) who have survived critical illness with symptoms of PTSD, discharged from intensive care and randomised to receive the intervention (n=160) or improved usual care (n=159) from a general practitioner.

INTERVENTIONS

Intervention group participants had three narrative exposure consultations with a general practitioner and eight scheduled contacts with a nurse. Control group participants received improved treatment as usual based on the German PTSD guideline.

MAIN OUTCOME MEASURES

The primary clinical outcome was self-reported PTSD symptoms using the Post-Traumatic Diagnostic Scale for DSM-5 (PDS-5, range 0-80, higher scores indicating more severe symptoms) at six months. The minimal clinically important difference was six points. Secondary outcomes included changes in depression, anxiety, patient activation, health related quality of life and disability at six and 12 months.

RESULTS

Between 21 October 2018 and 18 January 2023, 1283 patients discharged from an intensive care unit were screened for PTSD symptoms. 319 study participants were randomly assigned either to the control group (n=159) or the intervention group (n=160). The mean patient age was 57.7 years (standard deviation (SD) 12.7), and 61% of participants were male. The mean baseline PDS-5 score was 30.6 (SD 13.3) in both groups. 271 (85%) study participants completed follow-up assessment after six months and 247 (77%) after 12 months. The intervention effect showed a mean between-group difference in the PDS-5 score of 4.7 points ((95% confidence interval 1.6 to 7.8); P=0.003, Cohen's d=0.37)) at six months and 5.4 points ((1.8 to 9.0); P=0.003, Cohen's d=0.41)) at 12 months. Among secondary outcomes, patients in the intervention group had greater improvements in depression, health related quality of life, and disability.

CONCLUSIONS

In adults with symptoms of PTSD after critical illness, a brief narrative exposure intervention was feasible and showed a reduction of symptoms, which was less than the predefined minimal clinically important difference. The effect was found to be sustained at 12 months' follow-up. These findings support the further evaluation of this intervention in primary care.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03315390; DRKS-ID DRKS00012589.

Mental Health Clinician Practices and Perspectives on Treating Adults with Co-Occurring Posttraumatic Stress and Substance Use Disorders

OBJECTIVE

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) commonly co-occur and represent a complex, challenging clinical comorbidity. Meta-analytic studies and systematic reviews suggest that trauma-focused treatments are more efficacious than non-trauma focused interventions for co-occurring PTSD/SUD. However, relatively little is known about mental health clinicians' practices or preferences for treating co-occurring PTSD/SUD. The present study aimed to describe the current clinical practices of mental health clinicians who treat PTSD and/or SUD-related conditions and to assess interest in novel integrative treatments for PTSD/SUD.

METHODS

Licensed mental health clinicians (N = 76; Mage = 39.59, SD = 8.14) who treat PTSD and/or SUD completed an anonymous online survey from April 2021 to July 2021.

RESULTS

The majority (61.8%) of clinicians reported using integrative treatments for PTSD/SUD. The most commonly used trauma-focused treatments were 1) Cognitive Processing Therapy (CPT: 71.1%) and 2) Prolonged Exposure Therapy (PE: 68.4%) for PTSD. Approximately half (51.3%) of clinicians endorsed using Relapse Prevention (RP) for SUD. The vast majority (97.4%) of clinicians were somewhat or very interested in a new integrative CPT-RP intervention, and 94.7% of clinicians believed patients would be interested in a CPT-RP intervention. In the absence of an available evidence-based integrative treatment using CPT, 84.0% of clinicians reported modifying extant treatment protocols on their own to address PTSD and SUD concurrently.

CONCLUSIONS

The findings demonstrate mental health clinician support of integrative treatments for PTSD/SUD. The most commonly used trauma-focused intervention was CPT and clinicians expressed strong interest in an integrative intervention that combines CPT and RP. Implications for future treatment development are discussed.

A scoping review on two-stage randomized preference trial in the field of mental health and addiction

BACKGROUND

Randomized Controlled Trial is the most rigorous study design to test the efficacy and effectiveness of an intervention. Patient preference may negatively affect patient performance and decrease the generalizability of a trial to clinical population. Patient preference trial have particular implications in the field of mental health and addiction since mental health interventions are generally complex, blinding of intervention is often difficult or impossible, patients may have strong preference, and outcome measures are often subjective patient self-report which may be greatly influenced if patient's preference did not match with the intervention received.

METHODS

In this review, we have surveyed the application of two-stage randomized preference trial with focus on studies in the field of mental health and addiction. The study selection followed the guideline provided by Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

RESULTS

Six two-stage randomized preference trials (ten publications) have been identified in the field of mental health field and addiction. In these trials, the pooled dropout rates were 18.3% for the preference arm, and 28.7% for the random arm, with a pooled RR of 0.70 (95% CI, 0.56-0.88; P = 0.010) indicating lower risk of dropout in the preference arm. The standardized preference effects varied widely from 0.07 to 0.57, and could be as large as the treatment effect in some of the trials.

CONCLUSION

This scoping review has shown that two-stage randomized preference trials are not as popular as expected in mental health research. The results indicated that two-stage randomized preference trials in mental health would be beneficial in retaining patients to expand the generalizability of the trial.

Shared decision-making interventions for people with mental health conditions

BACKGROUND

One person in every four will suffer from a diagnosable mental health condition during their life. Such conditions can have a devastating impact on the lives of the individual and their family, as well as society.  International healthcare policy makers have increasingly advocated and enshrined partnership models of mental health care. Shared decision-making (SDM) is one such partnership approach. Shared decision-making is a form of service user-provider communication where both parties are acknowledged to bring expertise to the process and work in partnership to make a decision.  This review assesses whether SDM interventions improve a range of outcomes. This is the first update of this Cochrane Review, first published in 2010.

OBJECTIVES

To assess the effects of SDM interventions for people of all ages with mental health conditions, directed at people with mental health conditions, carers, or healthcare professionals, on a range of outcomes including: clinical outcomes, participation/involvement in decision-making process (observations on the process of SDM; user-reported, SDM-specific outcomes of encounters), recovery, satisfaction, knowledge, treatment/medication continuation, health service outcomes, and adverse outcomes.

SEARCH METHODS

We ran searches in January 2020 in CENTRAL, MEDLINE, Embase, and PsycINFO (2009 to January 2020). We also searched trial registers and the bibliographies of relevant papers, and contacted authors of included studies.  We updated the searches in February 2022. When we identified studies as potentially relevant, we labelled these as studies awaiting classification.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including cluster-randomised controlled trials, of SDM interventions in people with mental health conditions (by Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

This updated review included 13 new studies, for a total of 15 RCTs. Most participants were adults with severe mental illnesses such as schizophrenia, depression, and bipolar disorder, in higher-income countries. None of the studies included children or adolescents.  Primary outcomes We are uncertain whether SDM interventions improve clinical outcomes, such as psychiatric symptoms, depression, anxiety, and readmission, compared with control due to very low-certainty evidence. For readmission, we conducted subgroup analysis between studies that used usual care and those that used cognitive training in the control group. There were no subgroup differences. Regarding participation (by the person with the mental health condition) or level of involvement in the decision-making process, we are uncertain if SDM interventions improve observations on the process of SDM compared with no intervention due to very low-certainty evidence. On the other hand, SDM interventions may improve SDM-specific user-reported outcomes from encounters immediately after intervention compared with no intervention (standardised mean difference (SMD) 0.63, 95% confidence interval (CI) 0.26 to 1.01; 3 studies, 534 participants; low-certainty evidence). However, there was insufficient evidence for sustained participation or involvement in the decision-making processes. Secondary outcomes We are uncertain whether SDM interventions improve recovery compared with no intervention due to very low-certainty evidence. We are uncertain if SDM interventions improve users' overall satisfaction. However, one study (241 participants) showed that SDM interventions probably improve some aspects of users' satisfaction with received information compared with no intervention: information given was rated as helpful (risk ratio (RR) 1.33, 95% CI 1.08 to 1.65); participants expressed a strong desire to receive information this way for other treatment decisions (RR 1.35, 95% CI 1.08 to 1.68); and strongly recommended the information be shared with others in this way (RR 1.32, 95% CI 1.11 to 1.58). The evidence was of moderate certainty for these outcomes. However, this same study reported there may be little or no effect on amount or clarity of information, while another small study reported there may be little or no change in carer satisfaction with the SDM intervention. The effects of healthcare professional satisfaction were mixed: SDM interventions may have little or no effect on healthcare professional satisfaction when measured continuously, but probably improve healthcare professional satisfaction when assessed categorically. We are uncertain whether SDM interventions improve knowledge, treatment continuation assessed through clinic visits, medication continuation, carer participation, and the relationship between users and healthcare professionals because of very low-certainty evidence. Regarding length of consultation, SDM interventions probably have little or no effect compared with no intervention (SDM 0.09, 95% CI -0.24 to 0.41; 2 studies, 282 participants; moderate-certainty evidence). On the other hand, we are uncertain whether SDM interventions improve length of hospital stay due to very low-certainty evidence. There were no adverse effects on health outcomes and no other adverse events reported.

AUTHORS' CONCLUSIONS

This review update suggests that people exposed to SDM interventions may perceive greater levels of involvement immediately after an encounter compared with those in control groups. Moreover, SDM interventions probably have little or no effect on the length of consultations.  Overall we found that most evidence was of low or very low certainty, meaning there is a generally low level of certainty about the effects of SDM interventions based on the studies assembled thus far. There is a need for further research in this area.

Functional outcomes from psychotherapy for people with posttraumatic stress disorder: A meta-analysis

People with posttraumatic stress disorder (PTSD) experience a wide array of symptoms, often accompanied by significant functional and quality of life impairments. Evidence-based psychotherapies are effective for alleviating symptoms in this group, but functional outcomes following psychotherapy are understudied. This study aimed to synthesize existing work on functional outcomes of psychotherapy to conduct a meta-analytic investigation examining whether people with PTSD experience significant improvements in functioning and quality of life following a course of psychotherapy. A literature search was conducted for studies reporting results of randomized clinical trials of psychotherapies for people diagnosed with PTSD that included a functional or quality of life outcome measured at pre- and post-intervention. Both between-groups and within-groups analyses were conducted using a random effects model. Fifty-six independent samples were included. Results suggest that, on average, people with PTSD experience significant, moderate improvement in functional outcomes after a course of psychotherapy. Taken together, this meta-analysis represents a substantial advance in our understanding of functional outcomes of psychotherapy for people with PTSD. Findings suggest that psychotherapy is one vehicle through which functional outcomes may be improved for this group, though notably to a lesser degree than symptom improvement.

Pharmacotherapy for post traumatic stress disorder (PTSD)

BACKGROUND

Posttraumatic stress disorder (PTSD) is a prevalent and disabling disorder. Evidence that PTSD is characterised by specific psychobiological dysfunctions has contributed to a growing interest in the use of medication in its treatment.

OBJECTIVES

To assess the effects of medication for reducing PTSD symptoms in adults with PTSD.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 11, November 2020); MEDLINE (1946-), Embase (1974-), PsycINFO (1967-) and PTSDPubs (all available years) either directly or via the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR). We also searched international trial registers. The date of the latest search was 13 November 2020.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of pharmacotherapy for adults with PTSD.

DATA COLLECTION AND ANALYSIS

Three review authors (TW, JI, and NP) independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. We contacted investigators to obtain missing data. We stratified summary statistics by medication class, and by medication agent for all medications. We calculated dichotomous and continuous measures using a random-effects model, and assessed heterogeneity.

MAIN RESULTS

We include 66 RCTs in the review (range: 13 days to 28 weeks; 7442 participants; age range 18 to 85 years) and 54 in the meta-analysis.  For the primary outcome of treatment response, we found evidence of beneficial effect for selective serotonin reuptake inhibitors (SSRIs) compared with placebo (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.59 to 0.74; 8 studies, 1078 participants), which improved PTSD symptoms in 58% of SSRI participants compared with 35% of placebo participants, based on moderate-certainty evidence.  For this outcome we also found evidence of beneficial effect for the noradrenergic and specific serotonergic antidepressant (NaSSA) mirtazapine: (RR 0.45, 95% CI 0.22 to 0.94; 1 study, 26 participants) in 65% of people on mirtazapine compared with 22% of placebo participants, and for the tricyclic antidepressant (TCA) amitriptyline (RR 0.60, 95% CI 0.38 to 0.96; 1 study, 40 participants) in 50% of amitriptyline participants compared with 17% of placebo participants, which improved PTSD symptoms. These outcomes are based on low-certainty evidence. There was however no evidence of beneficial effect for the number of participants who improved with the antipsychotics (RR 0.51, 95% CI 0.16 to 1.67; 2 studies, 43 participants) compared to placebo, based on very low-certainty evidence. For the outcome of treatment withdrawal, we found evidence of a harm for the individual SSRI agents compared with placebo (RR 1.41, 95% CI 1.07 to 1.87; 14 studies, 2399 participants). Withdrawals were also higher for the separate SSRI paroxetine group compared to the placebo group (RR 1.55, 95% CI 1.05 to 2.29; 5 studies, 1101 participants). Nonetheless, the absolute proportion of individuals dropping out from treatment due to adverse events in the SSRI groups was low (9%), based on moderate-certainty evidence. For the rest of the medications compared to placebo, we did not find evidence of harm for individuals dropping out from treatment due to adverse events.

AUTHORS' CONCLUSIONS

The findings of this review support the conclusion that SSRIs improve PTSD symptoms; they are first-line agents for the pharmacotherapy of PTSD, based on moderate-certainty evidence. The NaSSA mirtazapine and the TCA amitriptyline may also improve PTSD symptoms, but this is based on low-certainty evidence. In addition, we found no evidence of benefit for the number of participants who improved following treatment with the antipsychotic group compared to placebo, based on very low-certainty evidence. There remain important gaps in the evidence base, and a continued need for more effective agents in the management of PTSD.

Which Trauma Treatment Suits me? Identification of Patients' Treatment Preferences for Posttraumatic Stress Disorder (PTSD)

Several psychotherapy treatments exist for posttraumatic stress disorder. This study examines the treatment preferences of treatment-seeking traumatized adults in Germany and investigates the reasons for their treatment choices. Preferences for prolonged exposure, cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), psychodynamic psychotherapy and stabilization were assessed via an online survey. Reasons for preferences were analyzed by means of thematic coding by two independent rates. 104 traumatized adults completed the survey. Prolonged exposure and CBT were each preferred by nearly 30%, and EMDR and psychodynamic psychotherapy were preferred by nearly 20%. Stabilization was significantly less preferred than all other options, by only 4%. Significantly higher proportions of patients were disinclined to choose EMDR and stabilization. Patients who preferred psychodynamic psychotherapy were significantly older than those who preferred CBT. Reasons underlying preferences included the perceived treatment mechanisms and treatment efficacy. Traumatized patients vary in their treatment preferences. Preference assessments may help clinicians comprehensively address patients' individual needs and thus improve therapy outcomes.

Focus on disability-free life expectancy: implications for health-related quality of life

BACKGROUND

Since the end of the industrial revolution, advances in public health and clinical medicine have contributed to dramatic decreases in infant and childhood mortality, improvements in health-related quality of life (HRQoL), increases in overall life expectancy (LE), and rectangularization of survival curves.

OBJECTIVES

In this article, we focus on disability that has occurred with the overall lengthening of LE in many populations and the implications this has for decreased HRQoL.

METHODS

We utilize the concept of rectangularization of population survival to depict the rising prevalence of disability associated with increased LE, especially among racial and ethnic minorities and people of low socioeconomic status (SES) and relate this to HRQoL.

RESULTS

Disability-free life expectancy (DFLE) and healthy life expectancy (HLE) are defined in terms of HRQoL. Specific attention is focused on disability experienced by disparate populations around the globe. By focusing on disparities in DFLE, and the need to expand LE to include HLE as a central component of HRQoL, this work provides an important counterpoint to the attention that has been paid to LE disparities according to race, gender, ethnicity, education, and SES.

DISCUSSION

By calling attention to those factors that appear to be the most important drivers of the differences in quality and length of DFLE between different groups (i.e., the components of the social gradient, exposure to chronic stress, systemic inflammation, and the psychological and biological mechanisms associated with the gut-brain axis) and, by logical extension, HRQoL, we hope to promote research in this arena with the ultimate goal of improving DFLE, HLE, and overall HRQoL, especially in disparate populations around the globe.

Preferences of people with type 2 diabetes for telemedical lifestyle programmes in Germany: protocol of a discrete choice experiment

INTRODUCTION

Telemedical lifestyle programmes for people with type 2 diabetes mellitus (T2DM) provide an opportunity to develop a healthier lifestyle and consequently to improve health outcomes. When implementing new programmes into standard care, considering patients' preferences may increase the success of the participants. This study aims to examine the preferences of people with T2DM with respect to telemedical lifestyle programmes, to analyse whether these preferences predict programme success and to explore the changes that may occur during a telemedical lifestyle intervention.

METHODS AND ANALYSIS

We outline the protocol of the development and assessment of a discrete choice experiment (DCE) to examine patient preferences in a telemedical lifestyle programme with regard to the functions of the online portal, communication, responsibilities, group activities and time requirements. To develop the design of the DCE, we conducted pilot work involving healthcare experts and in particular people with T2DM using cognitive pretesting. The final DCE is being implemented within a randomised controlled trial for investigating whether participation in a telemedical lifestyle intervention programme sustainably improves the HbA1c values in 850 members of a large German statutory health insurance with T2DM. Preferences are being assessed before and after participants complete the programme. The DCE data will be analysed using regression and latent class analyses.

ETHICS AND DISSEMINATION

The DCE study has been approved by the ethics committee of the medical faculty of the Heinrich Heine University Duesseldorf, registration number 2018-242-ProspDEuA, registered on 6 December 2018. The TeLIPro trial is registered at the US National Library of Medicine, registration number NCT03675919, registered on 15 September 2018. We aim to disseminate our results in peer-reviewed journals, at national and international conferences and among interested patient groups and the public.

Effect of Treatment Preference in Randomized Controlled Trials: Systematic Review of the Literature and Meta-Analysis

BACKGROUND

A significant limitation of the traditional randomized controlled trials is that strong preferences for (or against) one treatment may influence outcomes and/or willingness to receive treatment. Several trial designs incorporating patient preference have been introduced to examine the effect of treatment preference separately from the effects of individual interventions. In the current study, we summarized results from studies using doubly randomized preference trial (DRPT) or fully randomized preference trial (FRPT) designs and examined the effect of treatment preference on clinical outcomes.

METHODS

The current systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies using DRPT or FRPT design were identified using electronic databases, including PubMed, Cochrane Library, EMBASE, and Google Scholar between January 1989 and November 2018. All studies included in this meta-analysis were examined to determine the extent to which giving patients their preferred treatment option influenced clinical outcomes. The following data were extracted from included studies: study characteristics, sample size, study duration, follow-up, patient characteristics, and clinical outcomes. We further appraised risk of bias for the included studies using the Cochrane Collaboration's risk of bias tool.

RESULTS

The search identified 374 potentially relevant articles, of which 27 clinical trials utilized a DRPT or FRPT design and were included in the final analysis. Overall, patients who were allocated to their preferred treatment intervention were more likely to achieve better clinical outcomes [effect size (ES) = 0.18, 95% confidence interval (CI) 0.10-0.26]. Subgroup analysis also found that mental health as well as pain and functional disorders moderated the preference effect (ES = 0.23, 95% CI 0.11-0.36, and ES = 0.09, 95% CI 0.03-0.15, respectively).

CONCLUSIONS

Matching patients to preferred interventions has previously been shown to promote outcomes such as satisfaction and treatment adherence. Our analysis of current evidence showed that allowing patients to choose their preferred treatment resulted in better clinical outcomes in mental health and pain than giving them a treatment that is not preferred. These results underline the importance of incorporating patient preference when making treatment decisions.

The Lifetime Effects of Injury: Postintensive Care Syndrome and Posttraumatic Stress Disorder

Postintensive care syndrome (PICS) is a heterogeneous syndrome marked by physical, cognitive, and mental health impairments experienced by critical care survivors. It is a syndrome that bears significant human and health care costs. Additional research is needed to identify risk factors and diagnostic, preventative, and treatment strategies for PICS. Trauma intensive care unit patients are particularly vulnerable to posttraumatic stress disorder, which shares some of the adverse long-term consequences of PICS and also requires additional research into effective preventative and management strategies.