Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults

Feasibility of a trauma-focused internet- and mobile-based intervention for youth with posttraumatic stress symptoms

Background: Many youth with posttraumatic stress symptoms (PTSS) do not receive evidence-based care. Internet- and Mobile-Based Interventions (IMIs) comprising evidence-based trauma-focused components can address this gap, but research is scarce. Thus, we investigated the feasibility of a trauma-focused IMI for youth with PTSS.Methods: In a one-arm non-randomized prospective proof-of-concept study, 32 youths aged 15-21 years with clinically relevant PTSS (CATS ≥ 21) received access to a trauma-focused IMI with therapist guidance, comprising nine sessions on an eHealth platform accessible via web-browser. We used a feasibility framework assessing recruitment capability, sample characteristics, data collection, satisfaction, acceptability, study management abilities, safety aspects, and efficacy of the IMI in PTSS severity and related outcomes. Self-rated assessments took place pre-, mid-, post-intervention and at 3-month follow-up and clinician-rated assessments at baseline and post-intervention.Results: The sample mainly consisted of young adult females with interpersonal trauma and high PTSS levels (CATS, M = 31.63, SD = 7.64). The IMI sessions were found useful and comprehensible, whereas feasibility of trauma processing was perceived as difficult. Around one-third of participants (31%) completed the IMI's eight core sessions. The study completer analysis showed a significant reduction with large effects in self-rated PTSS at post-treatment [t(21) = 4.27; p < .001; d = 0.88] and follow-up [t(18) = 3.83; p = .001; d = 0.84], and clinician-rated PTSD severity at post-treatment [t(21) = 4.52; p < .001; d = 0.93]. The intention-to-treat analysis indicated significant reductions for PTSS at post-treatment and follow-up with large effect sizes (d = -0.97- -1.02). All participants experienced at least one negative effect, with the most common being the resurfacing of unpleasant memories (n = 17/22, 77%).Conclusion: The study reached highly burdened young adults. The IMI was accepted in terms of usefulness and comprehensibility but many youths did not complete all sessions. Exploration of strategies to improve adherence in trauma-focused IMIs for youth is warranted, alongside the evaluation of the IMI's efficacy in a subsequent randomized controlled trial.

[Evidence-based psychotherapy of posttraumatic stress syndrome-An update]

BACKGROUND

The aim of this article is to summarize the current state of research on the effectiveness of psychotherapeutic treatment of posttraumatic stress disorder (PTSD).

METHODS

The results of current meta-analyses and trend-setting individual studies are summarized and the most important forms of intervention are explained.

RESULTS

The psychotherapeutic treatment methods for PTSD are very effective, the effect sizes are large and superior to those of pharmacotherapy. Trauma exposure and cognitive restructuring are most effective. Trauma-focused procedures are generally superior to other forms of psychotherapy. A range of different cognitive behavioral procedures as well as eye movement desensitization and reprocessing are recommended. The most recent initial findings confirm a very good effectiveness for imagery rescripting methods as protective interventions without a formal confrontation with trauma. Individual therapy works better than group psychotherapy. In the group setting cognitive processing therapy has proven to be the best intervention. Trauma-focused treatment should also be used when comorbid conditions such as schizophrenia, bipolar disorder or addiction are present.

DISCUSSION

Trauma-focused psychotherapy in an individual setting is the treatment of choice for PTSD. A large selection of effective methods and well-reviewed manuals are available. The German language S3 guidelines are currently being updated.

Digital health-based exposure therapies for patients with posttraumatic stress disorder: A systematic review of randomized controlled trials

Although exposure therapies have established effects in treating posttraumatic stress disorder (PTSD), these therapies might be hindered by issues of cost, distance, time, and human resources, which are potentially alleviated by digital health. Despite the potential of digital health, there is currently no systematic review specifically evaluating digital health-based exposure therapies. We aimed to conduct a systematic literature review of randomized controlled trials (RCTs) examining the impact of digital health-based exposure therapies in treating patients with PTSD. A literature search was conducted from December 31, 2023, to February 22, 2024, using the PubMed, Web of Science, and PsycINFO databases. A total of 12 RCTs with 1,361 participants were included in the systematic review. These RCTs were conducted mainly in the United States and primarily enrolled military samples. Overall, the utility of digital health-based exposure therapies appeared plausible and comparable to that of in-person therapies. The dropout rate was counterintuitively high, potentially due to technological issues and the absence of personal connections. The findings suggest that digital health-based exposure therapies may potentially resolve the issues of cost, distance, time, and human resources in the treatment of patients with PTSD. Future RCTs should employ larger sample sizes. Addressing technological challenges and the absence of personal connection may be important in resolving the high dropout rate.

The development and evaluation of a virtual, asynchronous, trauma-focused treatment program for adult survivors of childhood interpersonal trauma

BACKGROUND

The long-term mental and physical health implications of childhood interpersonal trauma on adult survivors is immense, however, there is a lack of available trauma-focused treatment services that are widely accessible. This study, utilizing a user-centered design process, sought feedback on the initial design and development of a novel, self-paced psychoeducation and skills-based treatment intervention for this population.

AIMS

To explore the views and perspectives of adult survivors of childhood interpersonal trauma on the first two modules of an asynchronous trauma-focused treatment program.

METHODS

Fourteen participants from our outpatient hospital service who completed the modules consented to provide feedback on their user experience. A thematic analysis of the three focus groups was conducted.

RESULTS

Four major themes emerged from the focus groups: (1) technology utilization, (2) module content, (3) asynchronous delivery, and (4) opportunity for interactivity. Participants noted the convenience of the platform and the use of multimedia content to increase engagement and did not find the modules to be emotionally overwhelming.

CONCLUSIONS

Our research findings suggest that an asynchronous virtual intervention for childhood interpersonal trauma survivors may be a safe and acceptable way to provide a stabilization-focused intervention on a wider scale.

Changes in trauma appraisal during brief internet-based exposure and cognitive restructuring treatment for Arabic-speaking people with PTSD

Background: Maladaptive trauma appraisal plays an important role in the development and maintenance of posttraumatic stress disorder (PTSD). While studies have demonstrated the effectiveness of exposure and cognitive treatments for PTSD symptomatology, the effect of such treatments on specific trauma appraisals is still not well understood.Objective: The study investigated the effect of an exposure and a cognitive restructuring internet-based treatment on specific trauma appraisals in Arabic-speaking participants with PTSD.Method: 334 participants received either an exposure (n = 167) or a cognitive restructuring (n = 167) internet-based treatment. PTSD symptom severity (PCL-5) and specific trauma appraisals (TAQ) were assessed at pre- and post-treatment. Changes in specific trauma appraisals within and between the two treatments were analyzed using multi-group change modelling. Associations between changes in PTSD symptom severity and changes in trauma appraisals were evaluated using Pearson product-moment correlation. For both treatments, participants with versus without reliable improvement were compared regarding changes in specific trauma appraisals using Welch tests. Analyses were performed on 100 multiple imputed datasets.Results: Both treatments yielded significant changes in shame, self-blame, fear, anger, and alienation (all ps < .001). Changes in betrayal were only significant in the cognitive restructuring treatment (p < .001). There was no evidence of differences between treatments for any specific trauma appraisal. Changes in PTSD symptom severity were significantly associated with changes in trauma appraisals (all ps < .001). In both treatments, participants who experienced reliable improvement in PTSD symptom severity showed significantly larger pre- to post-treatment changes in specific trauma appraisals compared to those without reliable improvement. Again, differences in betrayal were only significant in the cognitive restructuring treatment.Conclusions: The findings indicate that both treatments are effective in reducing trauma appraisals in Arabic-speaking people with PTSD. Changes in trauma appraisal seem to be associated with changes in PTSD symptomatology.Trial registration: German Clinical Trials Register identifier: DRKS00010245.

Characteristics and Influencing Factors of Post-Traumatic Growth: A Cross-Sectional Study of Psychiatric Nurses Suffering from Workplace Violence in Guangdong China

Background

Workplace violence (WPV) had become an important issue that endangered the occupational safety of psychiatric nurses. A growing number of studies showed positive post-traumatic growth (PTG) resulting from coping with trauma.

Objective

To investigate the characteristics of PTG in psychiatric nurses who experienced violence in the workplace and analyze its influencing factors.

Methods

A total of 1202 psychiatric nurses participated in the study. From October 2022 to December 2022, this cross-sectional study collected data on psychiatric nurses from five tertiary hospitals in Guangdong Province, China. Twenty-item Chinese version post-traumatic growth inventory (PTGI), Jefferson Scale of Empathy Health Professional (JSE-HP), Confidence in Coping with Patient Aggression Instrument (CCPAI), Post-traumatic Stress Disorder Checklist-Civilian Version (PCL-C), and Connor-Davidson Resilience Scale (CD-RISC) measured PTG level, empathy, the confidence in coping with WPV, post-traumatic stress disorder, and resilience, respectively. Bivariate analysis and multiple linear regression explored potential influencing factors of PTG. This study complies with the EQUATOR (STROBE) checklist.

Results

The sample was composed of a total of 1202 psychiatric nurses suffering from WPV. The average score of PTGI in psychiatric nurses was above average (65.75 points; SD = 20.20). Linear regression analyses showed from single-child family (β=0.052,95% CI=0.342,5.409, P<0.05), education background (β=0.108,95% CI=1.833,5.097, P<0.001), the confidence in coping with patient aggression (β=0.106,95% CI=1.385,4.317, P<0.001), empathy (β=0.057,95% CI=0.312,4.374, P<0.05), and resilience (β=0.484,95% CI=7.737,9.575, P<0.001) were associated with PTG level.

Conclusion

Psychiatric nurses who were non-single child, had received higher education, had confidence in coping with patient aggression, had good resilience and strong empathy were prone to PTG after experiencing WPV. The study findings could help hospitals and nursing managers identify vulnerable individuals and take early intervention measures against such populations.

Internet- and mobile-based psychological interventions for post-traumatic stress symptoms in youth: a systematic review and meta-analysis

Psychological interventions can help reduce posttraumatic stress symptoms (PTSS) in youth, but many do not seek help. Internet- and mobile-based interventions (IMIs) show promise in expanding treatment options. However, the overall evidence on IMIs in reducing PTSS among youth remains unclear. This systematic review and meta-analysis investigated the efficacy of IMIs in PTSS reduction for youth exposed to traumatic events. A comprehensive literature search was conducted in January 2023 including non-randomized and randomized-controlled trials (RCT) investigating the effects of IMIs on PTSS in youth aged ≤25 years. Six studies were identified with five providing data for the meta-analysis. The majority of studies included youth with different types of trauma irrespective of PTSS severity at baseline (k = 5). We found a small within-group effect in reducing PTSS from baseline to post-treatment (g = -0.39, 95% CrI: -0.67 to -0.11, k = 5; n = 558; 9 comparisons). No effect emerged when comparing the effect of IMIs to control conditions (g = 0.04; 95%-CrI: -0.52 to 0.6, k = 3; n = 768; k = 3; 4 comparisons). Heterogeneity was low between and within studies. All studies showed at least some concerns in terms of risk of bias. Current evidence does not conclusively support the overall efficacy of IMIs in addressing youth PTSS. This review revealed a scarcity of studies investigating IMIs for youth exposed to traumatic events, with most being feasibility studies rather than adequately powered RCTs and lacking a trauma focus. This underscores the demand for more high-quality research.

Exposure Versus Cognitive Restructuring Techniques in Brief Internet-Based Cognitive Behavioral Treatment for Arabic-Speaking People With Posttraumatic Stress Disorder: Randomized Clinical Trial

BACKGROUND

Cognitive behavioral interventions delivered via the internet are demonstrably efficacious treatment options for posttraumatic stress disorder (PTSD) in underserved, Arabic-speaking populations. However, the role of specific treatment components remains unclear, particularly in conflict-affected areas of the Middle East and North Africa.

OBJECTIVE

This study aims to evaluate 2 brief internet-based treatments in terms of efficacy, including change in PTSD symptom severity during treatment. Both treatments were developed in line with Interapy, an internet-based, therapist-assisted cognitive behavioral therapy protocol for PTSD and adapted to the specific research question. The first treatment comprised self-confrontation and social sharing (exposure treatment; 6 sessions); the second comprised cognitive restructuring and social sharing (cognitive restructuring treatment; 6 sessions). The 2 treatments were compared with each other and with a waitlist control group.

METHODS

In total, 365 Arabic-speaking participants from the Middle East and North Africa (mean age 25.49, SD 6.68 y) with PTSD were allocated to cognitive restructuring treatment (n=118, 32.3%), exposure treatment (n=122, 33.4%), or a waitlist control group (n=125, 34.2%) between February 2021 and December 2022. PTSD symptom severity, posttraumatic maladaptive cognitions, anxiety, depressive and somatoform symptom severity, and quality of life were assessed via self-report at baseline and after treatment or waiting time. PTSD symptom severity was also measured throughout treatment or waiting time. Treatment satisfaction was assessed after treatment completion. Treatment use and satisfaction were compared between the 2 treatment conditions using appropriate statistical tests (eg, chi-square and Welch tests). Multiple imputation was performed to address missing data and evaluate treatment-associated changes. These changes were analyzed using multigroup change modeling in the completer and intention-to-treat samples.

RESULTS

Overall, 200 (N=240, 83.3%) participants started any of the treatments, of whom 123 (61.5%) completed the treatment. Treatment condition was not significantly associated with the proportion of participants who started versus did not start treatment (P=.20) or with treatment completion versus treatment dropout (P=.71). High treatment satisfaction was reported, with no significant differences between the treatment conditions (P=.48). In both treatment conditions, PTSD, anxiety, depressive and somatoform symptom severity, and posttraumatic maladaptive cognitions decreased, and quality of life improved significantly from baseline to the posttreatment time point (P≤.001 in all cases). Compared with the baseline assessment, overall PTSD symptom severity decreased significantly after 4 sessions in both treatment conditions (P<.001). Moreover, both treatment conditions were significantly superior to the waitlist control group regarding overall PTSD symptom severity (P<.001) and most other comorbid mental health symptoms (P<.001 to P=.03). Differences between the 2 conditions in the magnitude of change for all outcome measures were nonsignificant.

CONCLUSIONS

Internet-based cognitive behavioral treatments for PTSD focusing primarily on either self-confrontation or cognitive restructuring are applicable and efficacious for Arabic-speaking participants.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00010245; https://drks.de/search/de/trial/DRKS00010245.

Cognitive behavioural therapy (CBT) with and without exercise to reduce fear of falling in older people living in the community

BACKGROUND

Fear of falling (FoF) is a lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing. It is a common condition amongst older adults and may occur independently of previous falls. Cognitive behavioural therapy (CBT), a talking therapy that helps change dysfunctional thoughts and behaviour, with and without exercise, may reduce FoF, for example, by reducing catastrophic thoughts related to falls, and modifying dysfunctional behaviour.

OBJECTIVES

To assess the benefits and harms of CBT for reducing FoF in older people living in the community, and to assess the effects of interventions where CBT is used in combination with exercise.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1, 2023), MEDLINE Ovid (from 1946 to 11 January 2023), Embase Ovid (from 1980 to 11 January 2023), CINAHL Plus (Cumulative Index to Nursing and Allied Health Literature) (from 1982 to 11 January 2023), PsycINFO (from 1967 to 11 January 2023), and AMED (Allied and Complementary Medicine from 1985 to 11 January 2023). We handsearched reference lists and consulted experts for identifying additional studies.

SELECTION CRITERIA

This review included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs assessing CBT with and without exercise interventions compared to control groups with sham-treatment, or treatment as usual. We defined CBT as a collaborative, time-limited, goal-oriented, and structured form of speaking therapy. Included studies recruited community-dwelling older adults, with a mean population age of at least 60 years minus one standard deviation, and not defined by a specific medical condition.

DATA COLLECTION AND ANALYSIS

Two review authors used standard methodological procedures expected by Cochrane. For continuous data, as assessed by single- or multiple-item questionnaires, we report the mean difference (MD) with 95% confidence interval (CI) when studies used the same outcome measures, and standardised mean difference (SMD) when studies used different measures for the same clinical outcome. For dichotomous outcomes, we reported the treatment effects as risk ratios (RR) with 95% CIs. We measured the primary outcome, FoF, immediately, up to, and more than six months after the intervention. We analysed secondary outcomes of activity avoidance, occurrence of falls, depression, and quality of life when measured immediately after the intervention. We assessed risk of bias for each included study, using the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We selected 12 studies for this review, with 11 studies included for quantitative synthesis. One study could not be included due to missing information. Of the 11 individual studies, two studies provided two comparisons, which resulted in 13 comparisons. Eight studies were RCTs, and four studies were cluster-RCTs. Two studies had multiple arms (CBT only and CBT with exercise) that fulfilled the inclusion criteria. The primary aim of 10 studies was to reduce FoF. The 11 included studies for quantitative synthesis involved 2357 participants, with mean ages between 73 and 83 years. Study total sample sizes varied from 42 to 540 participants. Of the 13 comparisons, three investigated CBT-only interventions while 10 investigated CBT with exercise. Intervention duration varied between six and 156 hours, at a frequency between three times a week and monthly over an eight- to 48-week period. Most interventions were delivered in groups of between five and 10 participants, and, in one study, up to 25 participants. Included studies had considerable heterogeneity, used different questionnaires, and had high risks of bias. CBT interventions with and without exercise probably improve FoF immediately after the intervention (SMD -0.23, 95% CI -0.36 to -0.11; 11 studies, 2357 participants; moderate-certainty evidence). The sensitivity analyses did not change the intervention effect significantly. Effects of CBT with or without exercise on FoF may be sustained up to six months after the intervention (SMD -0.24, 95% CI -0.41 to -0.07; 8 studies, 1784 participants; very low-certainty evidence). CBT with or without exercise interventions for FoF probably sustains improvements beyond six months (SMD -0.28, 95% CI -0.40 to -0.15; 5 studies, 1185 participants; moderate-certainty of evidence). CBT interventions for reducing FoF may reduce activity avoidance (MD -2.57, 95% CI -4.67 to -0.47; 1 study, 312 participants; low-certainty evidence), and level of depression (SMD -0.41, 95% CI -0.60 to -0.21; 2 studies, 404 participants; low-certainty evidence). We are uncertain whether CBT interventions reduce the occurrence of falls (RR 0.96, 95% CI 0.66 to 1.39; 5 studies, 1119 participants; very low-certainty evidence). All studies had a serious risk of bias, due to performance bias, and at least an unclear risk of detection bias, as participants and assessors could not be blinded due to the nature of the intervention. Downgrading of certainty of evidence also occurred due to heterogeneity between studies, and imprecision, owing to limited sample size of some studies. There was no reporting bias suspected for any article. No studies reported adverse effects due to their interventions.

AUTHORS' CONCLUSIONS

CBT with and without exercise interventions probably reduces FoF in older people living in the community immediately after the intervention (moderate-certainty evidence). The improvements may be sustained during the period up to six months after intervention (low-certainty evidence), and probably are sustained beyond six months (moderate-certainty evidence). Further studies are needed to improve the certainty of evidence for sustainability of FoF effects up to six months. Of the secondary outcomes, we are uncertain whether CBT interventions for FoF reduce the occurrence of falls (very low-certainty evidence). However, CBT interventions for reducing FoF may reduce the level of activity avoidance, and may reduce depression (low-certainty evidence). No studies reported adverse effects. Future studies could investigate different populations (e.g. nursing home residents or people with comorbidities), intervention characteristics (e.g. duration), or comparisons (e.g. CBT versus exercise), investigate adverse effects of the interventions, and add outcomes (e.g. gait analysis). Future systematic reviews could search specifically for secondary outcomes.

PROTOCOL: Group-based interventions for posttraumatic stress disorder: A systematic review and meta-analysis of the role of trauma type

This is the protocol for a Campbell systematic review. The primary objective is to assess the effects of group-based treatments on posttraumatic stress disorder (PTSD) symptomology in people diagnosed with PTSD (by a clinician or screening instrument) or referred to a PTSD treatment group for their symptoms by a medical professional. We will also examine a range of moderators that may affect the efficacy of group-based treatments, including the nature of the trauma (interpersonal, stigmatized) and the group fit (in terms of gender and shared vs. unshared trauma). Further, we will also explore what, if any, group-based and social identity factors are recorded and how they relate to PTSD outcomes.

[Outpatient rehabilitative care for patients with Long-COVID - a guideline-based clinical practice guideline]

BACKGROUND

Even after weeks and months, persisting and also newly occurring symptoms after SARS-CoV-2 infection are common and lead in many cases to a broad spectrum of impairments and participation restrictions in all areas of daily life. Scientific evidence on therapeutic options still is limited. The aim of this work is therefore to provide pragmatic treatment recommendations analogous to the current therapeutic appliances guideline.

METHOD

In addition to a search in six electronic databases, the experiences from the treatment of more than hundred affected persons from the post-COVID outpatient rehabilitation service were used. Additionally, experiences with patients with similar symptoms from other diseases were included. All authors worked together to develop the pragmatic recommendations for the treatment of the main symptoms within the framework of outpatient therapy measures. A list of recommended diagnostics and functional assessments prior to therapy was also developed.

RESULTS

For the main symptoms fatigue, dyspnoea and cognitive impairment, the catalog of therapeutic products offers a wide range of therapeutic options under the diagnosis U09.9. The therapy packages should be composed individually and adapted to the patient's performance level that regularly should be (re-)assessed. Informing the patient about possible relapses and deteriorations and how to deal with them should be also part of the treatment regimen.

DISCUSSION

Physical modalities and rehabilitation interventions should be used in out-patient rehabilitation setting for the treatment of Long-COVID. In this regard, it is also important to take into account and treat serious complications after the disease, such as post-intensive care syndrome. Due to the rapid evolution of the knowledge a frequent review of scientific papers and recommendations should be conducted. High-quality intervention studies are necessary to achieve greater evidence in this field.

[Differential Effects of an Internet-Based Cognitive-Behavioral Writing Therapy for Reducing PTSD Symptoms after Intensive Care: Results of a Per-Protocol Analysis]

OBJECTIVE

To investigate the differential effects of an internet-based cognitive-behavioral writing therapy (iCBT) on post-traumatic stress disorder (PTSD) symptoms after intensive care in patients and their spouses.

METHODS

This reanalysis of a randomized controlled trial compared PTSD symptom severity (measured by PCL-5) before and after therapy considering potential influencing factors in the per-protocol population.

RESULTS

A significant reduction in post-traumatic symptom severity after iCBT was found. Eleven of the 25 treated participants showed a clinically significant change (PCL-5 difference≥10 points). The number of words written by the participants in the therapy modules had a significant impact on iCBT efficacy.

CONCLUSION

iCBT appears to be a promising option to augment therapy for PTSD, particularly for physically impaired patients following critical illness.

Effectiveness of Telerehabilitation Interventions for Self-management of Tinnitus: Systematic Review

BACKGROUND

Tinnitus is a highly prevalent symptom affecting 10%-20% of the adult population. Most patients with tinnitus have chronic tinnitus, which can directly or indirectly disrupt their daily life and negatively affect the health-related quality of life. Therefore, patients with tinnitus are frequently in need of costly and time-consuming treatments. As an answer, telerehabilitation interventions are on a rise to promote self-management in patients with tinnitus and reduce their dependency on in-person care.

OBJECTIVE

This systematic review aimed to provide an overview of the research concerning the effectiveness of telerehabilitation interventions for self-management of tinnitus.

METHODS

This systematic review adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were eligible for inclusion if study participants were adult patients with complaints of primary subjective tinnitus and the study intervention comprised any possible telerehabilitation form for the self-management of tinnitus complaints. A search for eligible studies was conducted on PubMed, ScienceDirect, Scopus, Web of Science, and Cochrane Library. The Cochrane Risk of Bias 2 tool was used to the assess risk of bias.

RESULTS

In total, 29 articles were found eligible, and of these, 5 (17%) studied multiple telerehabilitation forms. Internet-based cognitive behavioral treatment with guidance by a psychologist or audiologist was examined in 17 studies (n=1767), internet-based cognitive behavioral treatment without guidance was examined in 4 studies (n=940), self-help manuals were examined in 1 study (n=72), technological self-help devices were examined in 2 studies (n=82), smartphone apps were examined in 8 studies (n=284), and other internet-based interventions were examined in 2 studies (n=130). These rehabilitation categories were proven to be effective in decreasing tinnitus severity and relieving tinnitus distress as measured by tinnitus questionnaires such as Tinnitus Functional Index, Tinnitus Handicap Inventory, or Tinnitus Reactions Questionnaire. However, dropout rates were often high (range 4%-71.4%). All studies reported between some concerns and high concerns of risk of bias, resulting in low to moderate certainty levels.

CONCLUSIONS

Overall, there is low to moderate quality evidence that telerehabilitation interventions effectively reduce tinnitus severity and distress. These interventions form a possible tool to improve the self-management capacities of the patient and the accessibility of tinnitus care as a replacement or an addition to in-person care. Nevertheless, barriers such as lack of time, engagement, motivation, and openness of the patient causing high dropout should be considered.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42021285450; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=285450.

Internet-Based Prevention Program of Victimization for Youth in Care and Care Leavers (EMPOWER YOUTH): Protocol for a Randomized Controlled Trial

BACKGROUND

The global estimate of the number of children in institutional care is around 5 million, with around 1 million of these children living in Europe. In Germany, about 75,000 children and adolescents find themselves in the foster care system and about 93,000 additional children and adolescents are living in institutions. Traumatic experiences and neglect in childhood are highly prevalent among these youth in care and are related to severe long-term effects. Childhood maltreatment and abuse can increase the risk of future victimization experiences. Although youth in care are at risk of victimization or revictimization, no specific evidence-based prevention program has been designed to address these specific needs.

OBJECTIVE

This study aims to evaluate the efficacy of a newly developed 6-module internet-based prevention program of victimization for youth in care, named EMPOWER YOUTH.

METHODS

In a randomized controlled trial, the intervention group will be compared to a waiting-list control group with an unblinded 1:1 allocation ratio. Assessments will take place before randomization (baseline) and at follow-up 18 weeks after baseline (ie, 12 weeks after finishing the last module of the program). The primary endpoint is the number of victimization, and online and offline bullying experiences (composite score) at the 18-week follow-up. Secondary endpoints are risk-taking behavior, aggressive tendencies, empathy, prosocial behavior, depressiveness, and loneliness at follow-up. The expected outcome requires a sample size of 156 subjects to achieve a power of 80%. Assuming a 30% dropout rate at follow-up, we require 225 participants to be allocated to the trial. Participants are youth in care, that is, adolescents in foster care, adopted adolescents, or young care leavers aged 14 to 21 years.

RESULTS

Ethical approval was granted by the Ethics Committee of the Medical School Berlin in March 2021 (MSB-2021/55). Recruitment started in September 2021 and is planned until November 2022. The results are expected to be published in January 2023.

CONCLUSIONS

Given the increased likelihood for future victimization experiences among youth in care, there is a strong need for a low-threshold intervention specifically for this high-risk age group. There are no existing nationwide mental health programs exclusively for youth in care in Germany.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00024749; https://tinyurl.com/tjaahayw.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34706.

Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults

BACKGROUND

Therapist-delivered trauma-focused psychological therapies are effective for post-traumatic stress disorder (PTSD) and have become the accepted first-line treatments. Despite the established evidence-base for these therapies, they are not always widely available or accessible. Many barriers limit treatment uptake, such as the number of qualified therapists available to deliver the interventions; cost; and compliance issues, such as time off work, childcare, and transportation, associated with the need to attend weekly appointments. Delivering Internet-based cognitive and behavioural therapy (I-C/BT) is an effective and acceptable alternative to therapist-delivered treatments for anxiety and depression.

OBJECTIVES

To assess the effects of I-C/BT for PTSD in adults.

SEARCH METHODS

We searched MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials to June 2020. We also searched online clinical trial registries and reference lists of included studies and contacted the authors of included studies and other researchers in the field to identify additional and ongoing studies.

SELECTION CRITERIA

We searched for RCTs of I-C/BT compared to face-to-face or Internet-based psychological treatment, psychoeducation, wait list, or care as usual. We included studies of adults (aged over 16 years), in which at least 70% of the participants met the diagnostic criteria for PTSD, according to the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed abstracts, extracted data, and entered data into Review Manager 5. The primary outcomes were severity of PTSD symptoms and dropouts. Secondary outcomes included diagnosis of PTSD after treatment, severity of depressive and anxiety symptoms, cost-effectiveness, adverse events, treatment acceptability, and quality of life. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data using a fixed-effect meta-analysis, except where heterogeneity was present, in which case we used a random-effects model. We independently assessed the included studies for risk of bias and we evaluated the certainty of available evidence using the GRADE approach; we discussed any conflicts with at least one other review author, with the aim of reaching a unanimous decision.

MAIN RESULTS

We included 13 studies with 808 participants. Ten studies compared I-C/BT delivered with therapist guidance to a wait list control. Two studies compared guided I-C/BT with I-non-C/BT. One study compared guided I-C/BT with face-to-face non-C/BT. There was substantial heterogeneity among the included studies. I-C/BT compared with face-to-face non-CBT Very low-certainty evidence based on one small study suggested face-to-face non-CBT may be more effective than I-C/BT at reducing PTSD symptoms post-treatment (MD 10.90, 95% CI 6.57 to 15.23; studies = 1, participants = 40). There may be no evidence of a difference in dropout rates between treatments (RR 2.49, 95% CI 0.91 to 6.77; studies = 1, participants = 40; very low-certainty evidence). The study did not measure diagnosis of PTSD, severity of depressive or anxiety symptoms, cost-effectiveness, or adverse events. I-C/BT compared with wait list Very low-certainty evidence showed that, compared with wait list, I-C/BT may be associated with a clinically important reduction in PTSD post-treatment (SMD -0.61, 95% CI -0.93 to -0.29; studies = 10, participants = 608). There may be no evidence of a difference in dropout rates between the I-C/BT and wait list groups (RR 1.25, 95% CI 0.97 to 1.60; studies = 9, participants = 634; low-certainty evidence). I-C/BT may be no more effective than wait list at reducing the risk of a diagnosis of PTSD after treatment (RR 0.53, 95% CI 0.28 to 1.00; studies = 1, participants = 62; very low-certainty evidence). I-C/BT may be associated with a clinically important reduction in symptoms of depression post-treatment (SMD -0.51, 95% CI -0.97 to -0.06; studies = 7, participants = 473; very low-certainty evidence). Very low-certainty evidence also suggested that I-C/BT may be associated with a clinically important reduction in symptoms of anxiety post-treatment (SMD -0.61, 95% CI -0.89 to -0.33; studies = 5, participants = 345). There were no data regarding cost-effectiveness. Data regarding adverse events were uncertain, as only one study reported an absence of adverse events. I-C/BT compared with I-non-C/BT There may be no evidence of a difference in PTSD symptoms post-treatment between the I-C/BT and I-non-C/BT groups (SMD -0.08, 95% CI -0.52 to 0.35; studies = 2, participants = 82; very low-certainty evidence). There may be no evidence of a difference between dropout rates from the I-C/BT and I-non-C/BT groups (RR 2.14, 95% CI 0.97 to 4.73; studies = 2, participants = 132; I² = 0%; very low-certainty evidence). Two studies found no evidence of a difference in post-treatment depressive symptoms between the I-C/BT and I-non-C/BT groups (SMD -0.12, 95% CI -0.78 to 0.54; studies = 2, participants = 84; very low-certainty evidence). Two studies found no evidence of a difference in post-treatment symptoms of anxiety between the I-C/BT and I-non-C/BT groups (SMD 0.08, 95% CI -0.78 to 0.95; studies = 2, participants = 74; very low-certainty evidence). There were no data regarding cost-effectiveness. Data regarding adverse effects were uncertain, as it was not discernible whether adverse effects reported were attributable to the intervention.

AUTHORS' CONCLUSIONS

While the review found some beneficial effects of I-C/BT for PTSD, the certainty of the evidence was very low due to the small number of included trials. This review update found many planned and ongoing studies, which is encouraging since further work is required to establish non-inferiority to current first-line interventions, explore mechanisms of change, establish optimal levels of guidance, explore cost-effectiveness, measure adverse events, and determine predictors of efficacy and dropout.