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. 2020 Aug 24;11(1):1795361. doi: 10.1080/20008198.2020.1795361

Non-pharmacological and non-psychological approaches to the treatment of PTSD: results of a systematic review and meta-analyses

Enfoques no farmacologicos y no psicologicos para el tratamiento del tept: Resultados de una revision sistematica y metanalisis

PTSD 的非药物和非心理学方法治疗：来自系统综述和元分析的结果

Jonathan I Bisson a,✉, Marieke van Gelderen b,c, Neil P Roberts a,d, Catrin Lewis a
PMCID: PMC7473142  PMID: 33029330

ABSTRACT

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.

KEYWORDS: Non-pharmacological, non-psychological, systematic review, PTSD treatment

Although a number of psychological and pharmacological treatments have been shown to be effective for the treatment of post-traumatic stress disorder (PTSD) (Hoskins et al., in review; Lewis, Roberts, Andrew, Starling, & Bisson, 2020), treatment resistance is common (Blanchard et al., 2003) and people with PTSD can find some interventions difficult to tolerate (Lewis, Roberts, Gibson, & Bisson, 2020). There is, therefore, a strong imperative to establish more effective and better-tolerated treatments for PTSD, including alternative management approaches to increase choice and address the preference of some people not to take medication or engage in psychological therapy. Anecdotal/proof of concept reports of their success have led to an increasing interest in alternative approaches and an increasingly robust evidence base being developed. This overview paper considers the 2018 ISTSS Prevention and Treatment Guidelines’ recommendations (International Society of Traumatic Stress Studies (ISTSS) [Online], 2018) regarding non-pharmacological and non-psychological interventions for PTSD and their implications for practice and future research.

The development process for the ISTSS Guidelines adhered to a strong methodology whereby PICO (Population, Intervention, Comparator, Outcomes) scoping questions were generated before any reviews or analyses were conducted (International Society of Traumatic Stress Studies (ISTSS) [Online], 2018). A key consideration was how to deal with interventions that were not pharmacological or psychological treatments. Such interventions include techniques commonly labelled as complementary or alternative therapies, for example, yoga and meditation, but also physical therapies such as transcranial magnetic stimulation (TMS) and neurofeedback.

The ISTSS Treatment Guidelines Committee included scoping questions that considered:

For adults with PTSD (and for children and adolescents with clinically relevant post-traumatic stress symptoms), do non-psychological and non-pharmacological treatments/interventions when compared to other treatments, treatment as usual, waiting list or no treatment, result in a reduction of symptoms, improved functioning/quality of life, presence of disorder, or adverse effects?

This paper presents the results of the systematic review and meta-analysis results pertaining to this scoping question as a short communication. The methodological process for addressing this question followed the same procedure as that outlined for the other ISTSS Guidelines scoping questions (Bisson et al., 2019) and is described in detail elsewhere (Hoskins et al., in review; Lewis et al., 2020). The methodology included risk of bias evaluations and data extraction procedures based on Cochrane Review guidelines (Higgins & Green, 2011) and an evaluation of the quality of findings using GRADE (Guyatt, Oxman, Schünemann, & Tugwell, 2011).

1. The evidence

Of the 327 randomised controlled trials (RCTs) included in the meta-analyses for the ISTSS Guidelines, 30 (9.2%) related to non-psychological and non-pharmacological interventions (28 in adults, two in children and adolescents). The individual studies, that covered a range of heterogeneous interventions, and risk of bias ratings are shown in Table 1.

Table 1.

Studies included in meta-analyses and risk of bias ratings.

Study Intervention N Trauma Control Random sequence generation Allocation concealment Blinding of outcome Incomplete outcome data assessment Selective reporting Other sources of bias
Ahmadizadeh and Rezaei (2018) TMS 58 Military veterans Sham TMS Unclear Low Low Low Unclear Low
Bormann, Thorp, Wetherell, Golshan, and Lang (2013) Mantram repetition 29 Military veterans WL/TAU Unclear Unclear Low Low Low High
Bormann, Thorp, Wetherell, and Golshan (2008) Mantram repetition 146 Military veterans WL/TAU Low Unclear Unclear High Unclear High
Bormann et al. (2018) Mantram repetition 173 Military veterans Present-centred therapy Low Low Low Low Low Low
Bremner et al. (2017) MBSR 17 Military
veterans		 Present-centred therapy Unclear Low High Unclear High High
Brom, Kleber, and Defares (1989) Hypnotherapy 79 Various WL/CBT-TF Unclear Unclear High Unclear Unclear High
Brom et al. (2017) Somatic experiencing 60 Various WL Low High Low Low Unclear High
Carr et al. (2012) Group music therapy 16 Various WL Low Low High Low Unclear High
Carter, Gerbarg, Brown, Ware, and D’Ambrosio (2013) Yoga 25 Military veterans TAU Low High Low High Unclear High
Cohen et al. (2004) TMS 16 Various Sham TMS Unclear Unclear Low High Unclear High
Davis et al. (2019) MBSR 191 Military veterans PCT Low Unclear Low Unclear Low Unclear
Gelkopf, Hasson-Ohayon, Bikman, and Kravetz (2013) Nature adventure therapy 42 Military WL Low Unclear Unclear High Unclear High
Goldstein et al. (2017) Group physical exercise 47 Military WL Unclear Unclear Low Low Low Low
Hollifield, Sinclair-Lian, Warner, and Hammerschlag (2007) Acupuncture 72 Various WL/CBT-TF Low Low Low Low Unclear Low
Kearney, McDermott, Malte, Martinez, and Simpson (2013) Group MBSR 47 Military WL/TAU Unclear Unclear Low Unclear Unclear High
Mitchell et al. (2014) Yoga 38 Various, females only WL/TAU Low Unclear Unclear Low Unclear High
Niles et al. (2012) MBSR 27 Military Psychoeducation Unclear High High Unclear Unclear High
Noohi, Miraghaie, and Arabi (2017) Neurofeedback 30 Various WL/TAU Unclear Unclear Unclear Unclear Unclear High
Numata et al. (2014) Saikokeishikankyoto (Japanese herbal formula) 43 Earthquake WL/TAU Low Low High Unclear Low Unclear
Polusny et al. (2015) MBSR 116 Military PCT Low Unclear Low Low High High
Reinhardt et al. (2018) Yoga 15 Military WL/TAU Low Unclear Unclear High Unclear High
Rosenbaum, Sherrington, and Tiedemann (2015) Physical exercise 58 Various WL/TAU Low Low Low Low Low Low
Schoorl, Putman, and Van Der Does (2013) Attentional bias modification 102 Various WL/TAU Low Low Low Low Low Low
Seppälä et al. (2014) Yoga 20 Military WL/TAU Low Unclear Low High Unclear High
van der Kolk et al. (2014) Yoga 64 Women interpersonal violence WL/TAU Unclear Unclear Low Low Low High
van der Kolk et al. (2016) Neurofeedback 44 Various WL/TAU Low Unclear Low Low Low Low
Wang, Hu, Wang, Pang, and Zhang (2012) Acupuncture 127 Earthquake Paroxetine Unclear Unclear Unclear Low Unclear Unclear
Watts, Landon, Groft, and Young-Xu (2012) TMS 20 Various Sham TMS Unclear Unclear Low Unclear Low High
Gordon, Staples, Blyta, Bytyqi, and Wilson (2008) Mind-body skills group 77 Children post-war WL/TAU Unclear High Unclear Low Low Low
Lyshak-Stelzer, Singer, Patricia, and Chemtob (2007) Trauma-focused expressive art therapy 29 Children various WL/TAU Unclear Unclear Low High Unclear High
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CBT-TF: cognitive-behavioural therapy with a trauma focus; MBSR: mindfulness-based stress reduction; PCT : present-centred therapy; TMS : transcranial magnetic stimulation; WL/TAU : wait list/treatment as usual.

Table 2 summarises the results of the meta-analyses undertaken with respect to specific interventions versus treatment as usual or wait list control.

Table 2.

Results of included interventions versus treatment as usual or wait list.

Intervention Description of intervention Summary result versus TAU/WL
(number of studies; number of participants; standardised mean difference; and 95% confidence intervals)		 GRADE judgement for quality of evidence
Transcranial magnetic stimulation (TMS)a Magnetic fields used repetitively to stimulate nerve cells in targeted areas of the brain. k = 3; N = 94; SMD −1.53, CI −2.76 to −0.30 Very uncertain about the estimate.
Mantram repetition Repeating a holy word(s) or phrase(s). k = 2; N = 175; SMD −0.27, CI −0.57 to 0.02 Very uncertain about the estimate.
Acupuncture Insertion of fine needles at specific points on the body (acupressure points). k = 1; N = 48; SMD −0.92, CI −1.51 to −0.32 Very uncertain about the estimate.
Hypnotherapy Hypnosis used to induce an altered state of consciousness before undertaking therapeutic work. k = 1; N = 52; SMD −0.04, CI −0.58 to 0.51 Very uncertain about the estimate.
Somatic experiencing Focuses on perceived body sensations and how to regulate these. k = 1; N = 60; SMD −0.75, CI −1.28 to −0.22 Very uncertain about the estimate.
Group music therapy Improvisation with musical instruments, with therapists providing improvised instrumental support and interaction. k = 1; N = 16; SMD −2.12, CI −3.41 to −0.83 Very uncertain about the estimate.
Yoga An integrative practice of body postures, breathing, and meditation. k = 5; N = 162; SMD −0.37, CI −0.68 to −0.05 Further research likely to have an important impact on confidence in the estimate of effect and likely to change the estimate.
Nature adventure therapy Engaging in outdoor group activities to support recovery. k = 1; N = 42; SMD −0.40, CI −1.01 to 0.22 Very uncertain about the estimate.
Mindfulness-based stress reduction Includes meditation practice, mindful awareness practice, and its application to real-life situations and to
facilitate acceptance
of traumatic memories.		 k = 1; N = 47; SMD −0.49, CI −1.07 to 0.09 Very uncertain about the estimate.
Neurofeedback Real-time displays of brain activity used to help individuals train (self-regulate) their brain activity. k = 2; N = 74; SMD −2.14, CI −4.20 to −0.08 Very uncertain about the estimate.
Saikokeishikankyoto Traditional Japanese herbal medicine. k = 1; N = 43; SMD −0.91, CI −1.55 to −0.28 Very uncertain about the estimate.
Physical exercise Usually a programme of aerobic exercise k = 2; N = 105; SMD −0.36, CI −0.75 to 0.03 Very uncertain about the estimate.
Attentional bias modification Computer-based training to keep attention away from threatening information k = 1; N = 102; SMD −0.23, CI −0.62 to 0.16 Very uncertain about the estimate.
Mind–body skills in children Using the mind to impact physical functioning k = 1; N = 77; SMD −0.37, CI −0.82 to 0.08 Very uncertain about the estimate.
Trauma-focused art therapy in children Using art as a medium for trauma-focused work k = 1; N = 30; SMD −1.46, CI −2.30 to −0.63 Very uncertain about the estimate.
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aControl condition for TMS was sham TMS.

In addition to RCTs that compared active interventions with TAU or WL, a number of studies compared one intervention with another. There was no evidence of a difference in four of these comparisons: acupuncture versus CBT with a trauma focus [k = 1; N = 48; SMD −0.35, CI −0.92 to 0.22]; hypnotherapy versus CBT with a trauma focus [k = 1; N = 56; SMD 0.34, CI −0.19 to 0.86]; electroacupuncture versus paroxetine [k = 1; N = 127; SMD −0.21, CI −0.56 to 0.14]; and mindfulness-based stress reduction versus present-centred therapy [k = 3; N = 324; SMD −0.07, CI −0.29 to 0.15]. One active treatment was superior to another in two comparisons: mantram repetition over present-centred therapy [k = 1; N = 173; SMD −0.37, CI −0.68 to −0.07]; and mindfulness-based stress reduction over psychoeducation [k = 1; N = 27; SMD −1.23, CI −2.07 to −0.40].

2. Quality of evidence

As illustrated in Table 2, the quality of evidence was judged as very low for all the interventions considered except yoga for which it was considered low, leading to significant uncertainty about the estimates generated. The quality of evidence was lower than found for pharmacological and psychological treatments (Hoskins et al., in review; Lewis et al., 2020). It is noteworthy, however, that the quality of some individual studies was high, as demonstrated by low risk of bias ratings in Table 1.

3. Recommendations

As a result of the evidence described above, six non-pharmacological and non-psychological interventions were recommended in the ISTSS Guidelines as interventions with emerging evidence for the treatment of PTSD in adults (see Table 3). There was insufficient evidence to recommend any non-pharmacological or non-psychological intervention for children.

Table 3.

ISTSS guideline interventions with emerging evidence for the treatment of PTSD.

  • Acupuncture

  • Neurofeedback

  • Saikokeishikankyoto

  • Somatic experiencing

  • Transcranial magnetic stimulation (TMS)

  • Yoga
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4. Discussion

The inclusion of emerging evidence recommendations for six different non-pharmacological and non-psychological interventions for the treatment of PTSD in the 2018 ISTSS Guidelines heralds a step change in the evidence-base available. Although more evidence is required before these interventions can be routinely recommended to people with PTSD, they offer alternative choices for people who may not have responded to or been able to tolerate interventions with better evidence or who would prefer an alternative approach. Several of the recommended interventions are already in widespread use and have an evidence-base for the treatment of other conditions.

Complementary therapies such as acupuncture and yoga have a developed evidence base for other health conditions (Bridges & Sharma, 2017; Smith, Armour, Lee, Wang, & Hay, 2018) but it is perhaps surprising that these are recommended above other established alternative approaches such as meditation. This may, however, reflect the dearth of RCTs in this area. Indeed, since the ISTSS Guidelines were completed, a large RCT of transcendental meditation (Nidich et al., 2018) in veterans with PTSD found it non-inferior to prolonged exposure and superior to health education.

Somatic experiencing has long been advocated as an effective approach to the management of PTSD with many practitioners and people with PTSD arguing for body-based interventions. Saikokeishikankyoto is not well known outside Japan but in Japan is a widely available herbal preparation and used for various ailments.

Neurofeedback has been used to treat PTSD since the 1980s (Peniston & Kulkosky, 1991) and the advent of MRI-assisted neurofeedback, as opposed to EEG-assisted neurofeedback, appears to have stimulated new interest in its use. Transcranial magnetic stimulation is now an approved treatment in many countries for treatment-resistant depression (NICE, 2015).

4.1. Limitations

Although the systematic review, meta-analysis and guideline development methodology adopted for the ISTSS Guidelines was of a very high standard, there are significant limitations with respect to the design of the primary trials included, many have high risks of bias and there is significant uncertainty with respect to the reliability of their findings. This is compounded in some instances by heterogeneous delivery of specific interventions across included studies, for example, for TMS and neurofeedback. There are also issues with respect to basing recommendations on comparisons with TAU/WL controls as opposed to other controls. For example, mantram repetition and mindfulness-based stress reduction were not recommended despite having shown superiority over present-centred therapy and psychoeducation, respectively. A challenge to the evaluation of all non-pharmacological interventions is the difficulty/impossibility of designing and conducting rigorous placebo-controlled, double-blind RCTs of them. The interventions considered were reported to be well tolerated, but there was limited measurement of tolerance and this was not formally assessed as part of the review.

4.2. Clinical implications

Given the level of evidence available, it would be premature to offer the recommended non-pharmacological and non-psychological interventions routinely, but they provide alternatives for people who do not respond to, do not tolerate or do not want more conventional evidence-based interventions. Some, e.g. yoga, are likely to be much more readily available and have been associated with less adverse effects than others. That said, even more invasive interventions such as transcranial magnetic stimulation have been well tolerated in the trials reported to date.

4.3. Research implications

A clear message is that people with PTSD can be helped by novel, alternative approaches, and this should stimulate further research to refine and standardise specific interventions (e.g. the TMS studies used different dosing regimens, complicating direct comparison) and also to subject the interventions with the most promise to more rigorous RCTs with larger samples to determine their true place in the treatment of PTSD. There is also a need for more mechanistic research to determine how specific interventions work, and for whom, to enable informed choices and a more personalised approach to the delivery of treatment to people with PTSD.

Acknowledgments

We would like to acknowledge the input and support of the Cochrane Collaboration and the International Society for Traumatic Stress Studies (ISTSS).

Funding Statement

This work was unfunded.

Author contribution

All authors were responsible for the original study design. The search was conducted by the Cochrane Collaboration. CL and MvG were responsible for data extraction, risk of bias assessments and data analysis. All authors were responsible for the interpretation of the analyses. All authors were involved in writing the report.

Disclosure statement

No potential conflict of interest was reported by the authors

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