Couple and family therapies for post‐traumatic stress disorder (PTSD)

Abstract

Background Post-traumatic stress disorder (PTSD) refers to an anxiety or trauma- and stressor-related disorder that is linked to personal or vicarious exposure to traumatic events. PTSD is associated with a range of adverse individual outcomes (e.g. poor health, suicidality) and significant interpersonal problems which include diGiculties in intimate and family relationships. A range of couple- and family-based treatments have been suggested as appropriate interventions for families impacted by PTSD. Objectives The objectives of this review were to: (1) assess the eGects of couple and family therapies for adult PTSD, relative to 'no treatment' conditions, 'standard care', and structured or non-specific individual or group psychological therapies; (2) examine the clinical characteristics of studies that influence the relative eGects of these therapies; and (3) critically evaluate methodological characteristics of studies that may bias the research findings. Search methods We searchedMEDLINE (1950-), Embase (1980-) andPsycINFO(1967-) via theCochraneCommonMentalDisordersControlledTrialsRegister (CCMDCTR) to 2014, then directly via Ovid aIer this date. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library. We conducted supplementary searches of PTSDPubs (all available years) (this database is formerly known as PILOTS (Published International Literature on Traumatic Stress)). We manually searched the early editions of key journals and screened the reference lists and bibliographies of included studies to identify other relevant research. We also contacted the authors of included trials for unpublished information. Studies have been incorporated from searches to 3 March 2018. Selection criteria Eligible studies were randomised controlled trials (RCTs) of couple or family therapies for PTSD in adult samples. The review considered any type of therapy that was intended to treat intact couples or families where at least one adult family member met criteria for PTSD. It was required that participants were diagnosed with PTSD according to recognised classification systems. Data collection and analysis We used the standard methodological procedures prescribed by Cochrane. Three review authors screened all titles and abstracts and two authors independently extracted data from each study deemed eligible and assessed the risk of bias for each study. We used odds ratios (OR) to summarise the eGects of interventions for dichotomous outcomes, and standardised mean diGerences (SMD) to summarise posttreatment between-group diGerences on continuous measures. Main results We included four trials in the review. Two studies examined the eGects of cognitive behavioural conjoint/couple's therapy (CBCT) relative to a wait list control condition, although one of these studies only reported outcomes in relation to relationship satisfaction. One study examined the eGects of structural approach therapy (SAT) relative to a PTSD family education (PFE) programme; and one examined the eGects of adjunct behavioural family therapy (BFT) but failed to report any outcome variables in suGicient detail — we did not include it in the meta-analysis. One trial with 40 couples (80 participants) showed that CBCT was more eGective than wait list control in reducing PTSD severity (SMD −1.12, 95% CI −1.79 to −0.45; low-quality evidence), anxiety (SMD −0.93, 95% CI −1.58 to −0.27; very low-quality evidence) and depression (SMD −0.66, 95% CI −1.30 to −0.02; very low-quality evidence) at post-treatment for the primary patient with PTSD. Data from two studies indicated that treatment and control groups did not diGer significantly according to relationship satisfaction (SMD 1.07, 95% CI −0.17 to 2.31; very low-quality evidence); and one study showed no significant diGerences regarding depression (SMD 0.28, 95% CI −0.35 to 0.90; very low-quality evidence) or anxiety symptoms (SMD 0.15, 95% CI −0.47 to 0.77; very low-quality evidence) for the partner of the patient with PTSD. One trial with 57 couples (114 participants) showed that SAT was more eGective than PFE in reducing PTSD severity for the primary patient (SMD −1.32, 95% CI −1.90 to −0.74; low-quality evidence) at post-treatment. There was no evidence of diGerences on the other outcomes, including relationship satisfaction (SMD 0.01, 95% CI −0.51 to 0.53; very low-quality evidence), depression (SMD 0.21, 95% CI −0.31 to 0.73; very low-quality evidence) and anxiety (SMD −0.16, 95% CI −0.68 to 0.36; very low-quality evidence) for intimate partners; and depression (SMD −0.28, 95% CI −0.81 to 0.24; very low-quality evidence) or anxiety (SMD −0.34, 95% CI −0.87 to 0.18; very low-quality evidence) for the primary patient. Two studies reported on adverse events and dropout rates, and no significant diGerences between groups were observed. Two studies were classified as having a 'low' or 'unclear' risk of bias in most domains, except for performance bias that was rated ‘high’. Two studies had significant amounts of missing information resulting in 'unclear'risk of bias. There were too few studies available to conduct subgroup analyses. Authors' conclusions There are few trials of couple-based therapies for PTSD and evidence is insuGicient to determine whether these oGer substantive benefits when delivered alone or in addition to psychological interventions. Preliminary RCTs suggest, however, that couple-based therapies for PTSD may be potentially beneficial for reducing PTSD symptoms, and there is a need for additional trials of both adjunctive and standalone interventions with couples orfamilies which targetreduced PTSD symptoms, mental health problems of family members and dyadic measures of relationship quality.