PTSD — Comparative psychotherapy evidence¶
TL;DR — Trauma-focused CBT variants and EMDR have the strongest adult evidence, but rankings are much more certain against waitlist than against active treatments (Mavranezouli 2020, PMID 32063234) (Lewis 2020, PMID 32284821). In the adult network meta-analysis, evidence was moderate-to-low quality; EMDR and TF-CBT maintained benefit at 1–4 months, while longer follow-up was sparse (Mavranezouli 2020, PMID 32063234). Exposure’s advantage was negligible versus other trauma-focused treatments or medication in a separate meta-analysis (McLean 2022, PMID 34954460). Delivered benefit must combine symptom change, remission, function, harms and probability of completion.
Why rankings mislead¶
A high probability of being ‘best’ can coexist with wide intervals, sparse direct evidence and clinically trivial differences. Network assumptions require transitivity across trauma type, severity, setting and comparator.
Comparator gradient¶
Effects are largest versus waitlist, smaller versus attention/non-trauma-focused therapy and smallest versus another bona fide trauma-focused treatment (McLean 2022, PMID 34954460).
Outcome choice¶
End-of-treatment symptom score, diagnostic remission, response threshold, functioning and follow-up durability are not interchangeable. Missing data assumptions can reverse ordering when dropout differs (Carpenter 2018, PMID 29451967), and the difference is not hypothetical: in the largest randomized CPT-versus-PE trial (n=916 veterans) dropout was 52.31% in PE against 45.77% in CPT (Harper 2026, PMID 41926191). A 157-RCT network and pairwise meta-analysis of 11,565 patients found that all psychological interventions beat control, that interventions did not differ significantly from one another overall, but that TF-CBT outperformed non-trauma-focused interventions at short (g=0.17, 95% CI 0.03–0.31), mid (g=0.23, 95% CI 0.06–0.40) and long term (g=0.20, 95% CI 0.04–0.35) — while slightly more patients dropped out of TF-CBT than non-trauma-focused treatment (RR 1.36, 95% CI 1.08–1.70) (Hoppen 2023, PMID 37141033). Efficacy and acceptability point in opposite directions by a small margin, which is precisely why they must be reported together.
Trauma focus¶
Trauma-focused approaches have the clearest support, yet present-centred and other non-trauma-focused therapies may offer benefit and acceptability. ‘Not statistically superior’ is not proof of equivalence (Lewis 2020, PMID 32284821).
Complexity and comorbidity¶
Component NMA in complex traumatic events suggests people with comorbid problems can benefit, but pooled comorbidity is not a PTSD-only stratum and should be labelled (Coventry 2020, PMID 32813696). Depression outcomes remain depression outcomes.
Evidence gaps¶
Most networks have limited long-term, functional, adverse-event and patient-preference data. Therapist competence and implementation context are rarely randomised.
Quantitative anchors¶
| Measure | Estimate | Population/method | Source |
|---|---|---|---|
| Adult NMA | 90 trials; n=6,560; 22 interventions | Moderate-to-low certainty | (Mavranezouli 2020, PMID 32063234) |
| Manualized review | 114 RCTs; n=8,171 | CBT-T and EMDR first-line | (Lewis 2020, PMID 32284821) |
| Exposure review | 65 articles; n=4,929 | Comparator gradient | (McLean 2022, PMID 34954460) |
| Broad review | 64 trials | Head-to-head evidence insufficient | (Cusack 2016, PMID 26574151) |
| Complex-trauma component NMA | psychological + pharmacological | Comorbidity/complex-event scope | (Coventry 2020, PMID 32813696) |
| Pediatric NMA | 70 RCTs; n=5,528 | Age-specific network | (Hoppen 2025, PMID 39630422) |
| Adult NMA + pairwise | 157 RCTs; n=11,565 | Efficacy and acceptability together | (Hoppen 2023, PMID 37141033) |
| TF-CBT vs non-TF, short term | g=0.17 (95% CI 0.03–0.31) | 190 comparisons | (Hoppen 2023, PMID 37141033) |
| TF-CBT vs non-TF, long term | g=0.20 (95% CI 0.04–0.35) | >5 months post-treatment; 41 comparisons | (Hoppen 2023, PMID 37141033) |
| TF-CBT vs non-TF dropout | RR 1.36 (95% CI 1.08–1.70) | 22 comparisons | (Hoppen 2023, PMID 37141033) |
| EMDR vs other therapies (IPD) | no significant difference (β=−0.24) | Individual participant data | (Wright 2024, PMID 38173121) |
Evidence ledger¶
The ledger lists the live-retrieved records used to bound this page. Inclusion does not make every record equally probative; design, population and comparator remain decisive.
| PMID | Year | Evidence contribution | Scope caution |
|---|---|---|---|
| 32063234 | 2020 | Psychological treatments for post-traumatic stress disorder in adults: a network meta-analysis. | Synthesis: preserve included-population and certainty limits |
| 32284821 | 2020 | Psychological therapies for post-traumatic stress disorder in adults: systematic review and meta-analysis. | Synthesis: preserve included-population and certainty limits |
| 26574151 | 2016 | Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. | Synthesis: preserve included-population and certainty limits |
| 34954460 | 2022 | Exposure therapy for PTSD: A meta-analysis. | Synthesis: preserve included-population and certainty limits |
| 32813696 | 2020 | Psychological and pharmacological interventions for posttraumatic stress disorder and comorbid mental health problems following complex traumatic events: Systematic review and component network meta-analysis. | Synthesis: preserve included-population and certainty limits |
| 29451967 | 2018 | Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. | Synthesis: preserve included-population and certainty limits |
| 34473342 | 2022 | Trauma-focused psychotherapies for post-traumatic stress disorder: A systematic review and network meta-analysis. | Synthesis: preserve included-population and certainty limits |
| 37141033 | 2023 | The efficacy and acceptability of psychological interventions for adult PTSD: A network and pairwise meta-analysis of randomized controlled trials. | Synthesis: preserve included-population and certainty limits |
| 37971855 | 2024 | Project harmony: A systematic review and network meta-analysis of psychotherapy and pharmacologic trials for comorbid posttraumatic stress, alcohol, and other drug use disorders. | Synthesis: preserve included-population and certainty limits |
| 32924926 | 2020 | Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review. | Synthesis: preserve included-population and certainty limits |
| 40001042 | 2025 | Mind-body intervention for post-traumatic stress disorder in adolescents: a systematic review and network meta-analysis. | Synthesis: preserve included-population and certainty limits |
| 40476517 | 2025 | Efficacy of psychosocial interventions on social functioning in individuals with childhood maltreatment experiences: a protocol for a systematic review and network meta-analysis. | Synthesis: preserve included-population and certainty limits |
| 31313834 | 2020 | Research Review: Psychological and psychosocial treatments for children and young people with post-traumatic stress disorder: a network meta-analysis. | Synthesis: preserve included-population and certainty limits |
| 34599050 | 2021 | Comparative efficacy and acceptability of psychotherapies for post-traumatic stress disorder in children and adolescents: a systematic review and network meta-analysis. | Synthesis: preserve included-population and certainty limits |
| 32353011 | 2020 | Cost-effectiveness of psychological treatments for post-traumatic stress disorder in adults. | PTSD-specific record; inspect design and population |
| 31654414 | 2020 | Cost-effectiveness of psychological interventions for children and young people with post-traumatic stress disorder. | PTSD-specific record; inspect design and population |
| 20546985 | 2010 | A meta-analytic review of prolonged exposure for posttraumatic stress disorder. | Synthesis: preserve included-population and certainty limits |
| 35278229 | 2022 | Less dropout from prolonged exposure sessions prescribed at least twice weekly: A meta-analysis and systematic review of randomized controlled trials. | Synthesis: preserve included-population and certainty limits |
| 20614457 | 2010 | Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD). | PTSD-specific record; inspect design and population |
| 24382682 | 2014 | Primum non nocere (first do no harm): symptom worsening and improvement in female assault victims after prolonged exposure for PTSD. | PTSD-specific record; inspect design and population |
| 34477098 | 2021 | Comparing treatments for post-traumatic stress disorder - a systematic review. | Synthesis: preserve included-population and certainty limits |
| 36628572 | 2023 | Comparative effectiveness of psychotherapies in adults with posttraumatic stress disorder: a network meta-analysis of randomised controlled trials. | Synthesis: preserve included-population and certainty limits |
| 35413848 | 2022 | The efficacy and acceptability of exposure therapy for the treatment of post-traumatic stress disorder in children and adolescents: a systematic review and meta-analysis. | Synthesis: preserve included-population and certainty limits |
| 31690461 | 2019 | Medication versus trauma-focused psychotherapy for adults with posttraumatic stress disorder: A systematic review and meta-analysis. | Synthesis: preserve included-population and certainty limits |
| 39630422 | 2025 | Psychological Interventions for Pediatric Posttraumatic Stress Disorder: A Systematic Review and Network Meta-Analysis. | Synthesis: preserve included-population and certainty limits |
| 41926191 | 2026 | Comparing dropout from cognitive processing therapy versus prolonged exposure: Results from a randomized clinical trial. | PTSD-specific record; inspect design and population |
| 38590124 | 2024 | Cognitive-behavioural conjoint therapy versus prolonged exposure for PTSD in military service members and veterans: results and lessons from a randomized controlled trial. | PTSD-specific record; inspect design and population |
| 23842024 | 2013 | Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. | Synthesis: preserve included-population and certainty limits |
| 38173121 | 2024 | EMDR v. other psychological therapies for PTSD: a systematic review and individual participant data meta-analysis. | Synthesis: preserve included-population and certainty limits |
Interpretation guardrails¶
- Trauma exposure, post-traumatic symptoms, acute stress disorder, DSM-5 PTSD, ICD-11 PTSD and ICD-11 complex PTSD are not interchangeable populations.
- A mixed-anxiety or transdiagnostic estimate is labelled as such; only a source’s PTSD stratum can be treated as a PTSD effect.
- Comorbid depression is measured separately and cross-linked to the depression condition; it is not absorbed into PTSD.
- Waitlist, treatment-as-usual, attention control and active treatment answer different causal questions.
- Registration, statistical significance and diagnostic loss do not respectively prove completion, clinical importance or functional recovery.
- This page synthesizes research and does not provide individual medical advice.
Minimum extraction frame for studies on this topic¶
| Field | What must be retained | Why it changes interpretation |
|---|---|---|
| Diagnostic system | DSM version, ICD version, full/subthreshold | Case mix is not interchangeable |
| Diagnostic method | Structured interview, clinician judgment, self-report cutoff | Screening is not diagnosis |
| Index trauma | Type, timing, repetition, direct/indirect/occupational | Conditional risk and phenotype differ |
| Population | Civilian, veteran, refugee, child/adolescent, mixed | Transportability is empirical |
| Baseline severity | Mean, SD, range and exclusion threshold | Ceiling and floor effects alter change |
| CPTSD status | ITQ/ICD-11 definition and DSO score | Complexity cannot be inferred from trauma count |
| Comorbidity | Depression, GAD, SUD, pain, TBI measured separately | Shared symptoms can distort effects |
| Comparator | Waitlist, usual care, attention, active treatment | The estimand changes with comparator |
| Treatment dose | Sessions offered/attended, duration, homework | Assignment is not exposure |
| Outcome | Symptoms, diagnosis, response, function, sleep | Outcomes are not interchangeable |
| Time point | End point and prespecified follow-up windows | Acute benefit may not persist |
| Missing data | Denominator, reasons, imputation and estimand | Attrition can bias rank and magnitude |
| Adverse events | Definitions, ascertainment and arm-level counts | Absence of reporting is not absence of harm |
| Therapist/context | Training, fidelity, allegiance, setting | Delivery is part of the intervention |
| Funding/conflicts | Sponsor role and analytic independence | Especially material for proprietary packages |
Claims this page does not make¶
- It does not infer PTSD from trauma exposure alone.
- It does not treat a self-report cutoff as equivalent to a structured diagnosis.
- It does not convert a pooled anxiety-disorder effect into a PTSD effect.
- It does not convert a depression outcome in a comorbid sample into a PTSD outcome.
- It does not infer superiority from a statistically significant within-group change.
- It does not infer equivalence from a non-significant between-group test.
- It does not infer effectiveness from trial registration or mechanistic plausibility.
- It does not assume military, civilian, refugee and pediatric estimates transport unchanged.
- It does not average conflicting estimates that use different definitions.
- It does not treat lack of adverse-event reporting as evidence of safety.
Evidence-updating triggers¶
| Trigger | Required response |
|---|---|
| New diagnostic revision | Recalculate which populations prior estimates represent |
| New head-to-head RCT | Compare against active treatment, not only waitlist |
| New individual-participant synthesis | Revisit effect modifiers and transportability |
| Registry status change | Verify results and linked publication before changing conclusions |
| Guideline update | Separate evidence review from panel recommendation |
| Regulatory decision | Record decision date and source; do not infer from efficacy papers |
| Safety signal | Re-extract denominator, ascertainment and exposure time by arm |
| Contradictory replication | Display estimates side by side; do not average definitions |
Evidence updates should preserve the prior estimate and explain why the new study changes—or does not change—the inference.
Open questions¶
- Can an IPD network meta-analysis estimate retention-adjusted, patient-centred treatment effects? (Mavranezouli 2020, PMID 32063234) (Harper 2026, PMID 41926191)
- Which apparent effect modifiers survive within-trial interaction testing? (McLean 2022, PMID 34954460)
- How stable are rankings when high-risk-of-bias and waitlist-controlled studies are removed? (Mavranezouli 2020, PMID 32063234)
Related pages¶
- prolonged-exposure — exposure evidence.
- cognitive-processing-therapy — cognitive trauma-focused evidence.
- emdr — EMDR evidence and component debate.
- dropout-and-nonresponse — missing outcomes and delivered benefit.
References¶
- Mavranezouli I, et al. Psychological treatments for post-traumatic stress disorder in adults: a network meta-analysis. Psychol Med. 2020;50(4):542-555. PMID 32063234
- Lewis C, et al. Psychological therapies for post-traumatic stress disorder in adults: systematic review and meta-analysis. Eur J Psychotraumatol. 2020;11(1):1729633. PMID 32284821
- Cusack K, et al. Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clin Psychol Rev. 2016;43:128-41. PMID 26574151
- McLean CP, et al. Exposure therapy for PTSD: A meta-analysis. Clin Psychol Rev. 2022;91:102115. PMID 34954460
- Coventry PA, et al. Psychological and pharmacological interventions for posttraumatic stress disorder and comorbid mental health problems following complex traumatic events: Systematic review and component network meta-analysis. PLoS Med. 2020;17(8):e1003262. PMID 32813696
- Carpenter JK, et al. Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depress Anxiety. 2018;35(6):502-514. PMID 29451967
- Jericho B, et al. Trauma-focused psychotherapies for post-traumatic stress disorder: A systematic review and network meta-analysis. Acta Psychiatr Scand. 2022;145(2):132-155. PMID 34473342
- Hoppen TH, et al. The efficacy and acceptability of psychological interventions for adult PTSD: A network and pairwise meta-analysis of randomized controlled trials. J Consult Clin Psychol. 2023;91(8):445-461. PMID 37141033
- Hien DA, et al. Project harmony: A systematic review and network meta-analysis of psychotherapy and pharmacologic trials for comorbid posttraumatic stress, alcohol, and other drug use disorders. Psychol Bull. 2024;150(3):319-353. PMID 37971855
- Melton H, et al. Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review. Health Technol Assess. 2020;24(43):1-312. PMID 32924926
- Bianjiang Z, et al. Mind-body intervention for post-traumatic stress disorder in adolescents: a systematic review and network meta-analysis. BMC Psychiatry. 2025;25(1):178. PMID 40001042
- Fares-Otero NE, et al. Efficacy of psychosocial interventions on social functioning in individuals with childhood maltreatment experiences: a protocol for a systematic review and network meta-analysis. Eur J Psychotraumatol. 2025;16(1):2508548. PMID 40476517
- Mavranezouli I, et al. Research Review: Psychological and psychosocial treatments for children and young people with post-traumatic stress disorder: a network meta-analysis. J Child Psychol Psychiatry. 2020;61(1):18-29. PMID 31313834
- Xiang Y, et al. Comparative efficacy and acceptability of psychotherapies for post-traumatic stress disorder in children and adolescents: a systematic review and network meta-analysis. Evid Based Ment Health. 2021;24(4):153-160. PMID 34599050
- Mavranezouli I, et al. Cost-effectiveness of psychological treatments for post-traumatic stress disorder in adults. PLoS One. 2020;15(4):e0232245. PMID 32353011
- Mavranezouli I, et al. Cost-effectiveness of psychological interventions for children and young people with post-traumatic stress disorder. J Child Psychol Psychiatry. 2020;61(6):699-710. PMID 31654414
- Powers MB, et al. A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clin Psychol Rev. 2010;30(6):635-41. PMID 20546985
- Levinson DB, et al. Less dropout from prolonged exposure sessions prescribed at least twice weekly: A meta-analysis and systematic review of randomized controlled trials. J Trauma Stress. 2022;35(4):1047-1059. PMID 35278229
- Hetrick SE, et al. Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2010;2010(7):CD007316. PMID 20614457
- Jayawickreme N, et al. Primum non nocere (first do no harm): symptom worsening and improvement in female assault victims after prolonged exposure for PTSD. Depress Anxiety. 2014;31(5):412-9. PMID 24382682
- Storm MP, et al. Comparing treatments for post-traumatic stress disorder - a systematic review. Dan Med J. 2021;68(9):A09200643. PMID 34477098
- Yunitri N, et al. Comparative effectiveness of psychotherapies in adults with posttraumatic stress disorder: a network meta-analysis of randomised controlled trials. Psychol Med. 2023;53(13):6376-6388. PMID 36628572
- Huang T, et al. The efficacy and acceptability of exposure therapy for the treatment of post-traumatic stress disorder in children and adolescents: a systematic review and meta-analysis. BMC Psychiatry. 2022;22(1):259. PMID 35413848
- Sonis J, et al. Medication versus trauma-focused psychotherapy for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Psychiatry Res. 2019;282:112637. PMID 31690461
- Hoppen TH, et al. Psychological Interventions for Pediatric Posttraumatic Stress Disorder: A Systematic Review and Network Meta-Analysis. JAMA Psychiatry. 2025;82(2):130-141. PMID 39630422
- Harper KL, et al. Comparing dropout from cognitive processing therapy versus prolonged exposure: Results from a randomized clinical trial. J Consult Clin Psychol. 2026;94(3):140-150. PMID 41926191
- Monson CM, et al. Cognitive-behavioural conjoint therapy versus prolonged exposure for PTSD in military service members and veterans: results and lessons from a randomized controlled trial. Eur J Psychotraumatol. 2024;15(1):2330305. PMID 38590124
- Watts BV, et al. Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. J Clin Psychiatry. 2013;74(6):e541-50. PMID 23842024
- Wright SL, et al. EMDR v. other psychological therapies for PTSD: a systematic review and individual participant data meta-analysis. Psychol Med. 2024;54(8):1580-1588. PMID 38173121