Multiple session early psychological interventions for the prevention of post‐traumatic stress disorder

Neil P Roberts; Neil J Kitchiner; Justin Kenardy; Lindsay Robertson; Catrin Lewis; Jonathan I Bisson

doi:10.1002/14651858.CD006869.pub3

Intervenciones psicológicas iniciales con sesiones múltiples para la prevención del trastorno por estrés postraumático

Declaraciones de intereses de los autores

Versión publicada: 08 agosto 2019 Historial de versiones

https://doi.org/10.1002/14651858.CD006869.pub3

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Resumen

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Antecedentes

La prevención de trastornos psicológicos a largo plazo después de un evento traumático es motivo de gran preocupación. Las revisiones sistemáticas han indicado que el informe psicológico individual no es una intervención efectiva para la prevención del trastorno por estrés postraumático (TEPT). Durante los últimos 20 años, se han desarrollado otras formas de intervención con el fin de prevenir el TEPT.

Objetivos

Examinar la eficacia de las intervenciones psicológicas dirigidas a la prevención del TEPT en individuos expuestos a un evento traumático pero no identificados como personas que experimentan dificultades psicológicas específicas, en comparación con condiciones de control (p.ej. atención habitual, lista de espera y ningún tratamiento) y otras intervenciones psicológicas.

Métodos de búsqueda

Se realizaron búsquedas en el Registro Cochrane Central de Ensayos Controlados (CENTRAL), MEDLINE, Embase, PsycINFO y en la base de datos de ProQuest's Published International Literature On Traumatic Stress (PILOTS) hasta el 3 de marzo 2018. Se realizó una búsqueda anterior de las bases de datos de CENTRAL y Ovid través del Registro de Ensayos Controlados del Grupo Cochrane de Trastornos Mentales Comunes (CCMD‐CTR) (hasta mayo 2016). Se realizaron búsquedas manuales en las listas de referencias de guías relevantes, revisiones sistemáticas e informes de estudios incluidos. Los estudios identificados se compartieron con expertos clave en el área.

Se realizó una búsqueda actualizada (15 de marzo 2019) y se colocaron los ensayos nuevos en el apartado de «en espera de clasificación». Los mismos serán incorporados en la próxima versión de esta revisión, según corresponda.

Criterios de selección

Se realizaron búsquedas de ensayos controlados aleatorios sobre cualquier intervención psicológica inicial con sesiones múltiples (dos o más sesiones) o tratamiento diseñado para prevenir los síntomas del TEPT. Se excluyeron las intervenciones psicológicas con sesiones individuales y grupales únicas. Las intervenciones de comparación incluyeron la lista de espera/atención habitual y la condición de control activo. Se incluyeron estudios de adultos que experimentaron un evento traumático y que cumplían con el criterio A1 de acuerdo con el Diagnostic and Statistical Manual (DSM‐IV) para el TEPT.

Obtención y análisis de los datos

Se introdujeron los datos en el programa informático Review Manager 5. Se analizaron los resultados categóricos como cocientes de riesgos (CR), y los resultados continuos como diferencias de medias (DM) o diferencias de medias estandarizadas (DME), con intervalos de confianza (IC) del 95%. Se agruparon los datos con un metanálisis de efectos fijos, excepto cuando se observó la presencia de heterogeneidad, en cuyo caso se utilizó un modelo de efectos aleatorios. Dos autores de revisión evaluaron de forma independiente los estudios incluidos en cuanto al riesgo de sesgo y discutieron cualquier conflicto con un tercer revisor.

Resultados principales

Ésta es una actualización de una revisión anterior.

Se incluyeron 27 estudios con 3963 participantes. El metanálisis incluyó 21 estudios con 2721 participantes. Diecisiete estudios compararon la intervención psicológica inicial de sesiones múltiples versus tratamiento habitual y cuatro estudios compararon la intervención psicológica inicial de sesiones múltiples con la condición de control activo.

La evidencia de certeza baja indicó que las intervenciones psicológicas iniciales de sesiones múltiples pueden ser más efectivas que la atención habitual para reducir el diagnóstico de TEPT a los tres a seis meses de seguimiento (CR 0,62; IC del 95%: 0,41 a 0,93; I²= 34%; estudios = 5; participantes = 758). Sin embargo, no hubo diferencias estadísticamente significativas después del tratamiento (CR 1,06; IC del 95%: 0,85 a 1,32; I² = 0%; estudios = 5; participantes = 556; evidencia de certeza muy baja) ni a los siete a 12 meses (CR 0,94; IC del 95%: 0,20 a 4,49; estudios = 1; participantes = 132; evidencia de certeza muy baja). El metanálisis indicó que no hubo diferencias estadísticas en los abandonos en comparación con la atención habitual (CR 1,34; IC del 95%: 0,91 a 1,95; ² = 34%; estudios = 11; participantes = 1154; evidencia de certeza baja). En la variable de evaluación primaria de tres a seis meses, la evidencia de certeza baja no indicó ninguna diferencia estadística entre los grupos en la reducción de la gravedad del TEPT (DME ‐0,10, IC del 95%: ‐0,22 a 0,02; I² = 34%; estudios = 15; participantes = 1921), la depresión (DME ‐0,04; IC del 95%: ‐0,19 a 0,10; I² = 6%; estudios = 7; participantes = 1009) o los síntomas de ansiedad (DME ‐0,05; IC del 95%: ‐0,19 a 0,10; I² = 2%; estudios = 6; participantes = 945).

Ningún estudio que comparara una intervención y un control activo informó de resultados para el diagnóstico de TEPT. La evidencia de certeza baja mostró que las intervenciones pueden estar asociadas con una tasa de abandono mayor que la condición de control activo (CR 1,61; IC del 95%: 1,11 a 2,34; estudios = 2; participantes = 425). A los tres a seis meses, la evidencia de certeza baja no indicó diferencias estadísticas entre las intervenciones en cuanto a la gravedad de los síntomas del TEPT (DME ‐0,02; IC del 95%: ‐0,31 a 0,26; I² = 43%; estudios = 4; participantes = 465), la depresión (DME 0,04, IC del 95%: ‐0,16 a 0,23; I² = 0%; estudios = 2; participantes = 409), la ansiedad (DME 0,00; IC del 95%: ‐0,19 a 0,19; I² = 0%; estudios = 2; participantes = 414) o la calidad de vida (DM ‐0,03; IC del 95%: ‐0,06 a 0,00; estudios = 1; participantes = 239).

Ninguno de los estudios incluidos informó sobre eventos adversos ni sobre el uso de recursos relacionados con la salud.

Conclusiones de los autores

Aunque la revisión encontró algunos efectos beneficiosos de las intervenciones psicológicas iniciales con sesiones múltiples en la prevención del TEPT, la certeza de la evidencia fue baja debido al alto riesgo de sesgo de los ensayos incluidos. La clara implicación práctica de lo anterior es que, en la actualidad, no se pueden recomendar las intervenciones de sesiones múltiples dirigidas a todas las personas expuestas a eventos traumáticos. Hay una serie de estudios en curso que demuestran que se trata de un área de investigación en rápida evolución. Las actualizaciones futuras de esta revisión integrarán los resultados de estos nuevos estudios.

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Resumen en términos sencillos

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Intervenciones psicológicas iniciales con sesiones múltiples para la prevención del trastorno por estrés postraumático

¿Por qué era importante esta revisión?

Los eventos traumáticos pueden tener un efecto significativo en la capacidad de las personas, las familias y las comunidades para sobrellevar la situación. En el pasado las intervenciones con sesiones únicas, como el informe psicológico, se utilizaban ampliamente para prevenir dificultades psicológicas continuas. Sin embargo, en revisiones anteriores se halló que las intervenciones con sesiones únicas no fueron efectivas para prevenir el trastorno por estrés postraumático (TEPT). Se desarrollaron distintas formas de intervenciones para tratar de evitar que los individuos expuestos a un trauma desarrollen TEPT.

¿Quién estará interesado en esta revisión?

• Personas expuestas a eventos traumáticos y sus seres queridos.

• Profesionales que trabajan en servicios de salud mental.

• Médicos generales.

• Comisionados.

¿Qué preguntas intenta responder esta revisión?

¿Las intervenciones psicológicas iniciales de sesiones múltiples (es decir, intervenciones de dos o más sesiones que comienzan dentro de los primeros tres meses después del evento traumático) son más efectivas que el tratamiento habitual u otra intervención psicológica para:

• reducir el número de pacientes con diagnóstico de TEPT;

• reducir la gravedad de los síntomas del TEPT;

• reducir la gravedad de los síntomas depresivos;

• reducir la gravedad de los síntomas de ansiedad;

• mejorar la funcionalidad general (p.ej. social, psicológica, profesional) de los receptores de la intervención?

¿Qué estudios se incluyeron en la revisión?

Se buscaron ensayos controlados aleatorios (estudios clínicos en que las personas son asignadas de forma aleatoria a uno de dos o más grupos de tratamiento) que examinaran las intervenciones psicológicas iniciales de sesiones múltiples para la prevención del TEPT, publicados entre 1970 y marzo 2018.

Se incluyeron 27 estudios con 3963 participantes.

¿Qué dice la evidencia de la revisión?

‐ Se encontró evidencia de certeza baja de que las intervenciones psicológicas iniciales de sesiones múltiples pueden ser más efectivas que el tratamiento habitual para prevenir el diagnóstico de TEPT de tres a seis meses después de recibir la intervención.

‐ Se encontró evidencia de certeza muy baja de que las intervenciones psicológicas iniciales de sesiones múltiples pueden ser ni más ni menos efectivas que el tratamiento habitual para prevenir el TEPT, ya sea inmediatamente después de la intervención o a los siete a 12 meses después de la misma. También se encontró evidencia de certeza muy baja de que las intervenciones psicológicas iniciales de sesiones múltiples pueden ser ni más ni menos efectivas que el tratamiento habitual para reducir la gravedad de los síntomas del TEPT, ya sea inmediatamente o en puntos posteriores del seguimiento.

‐ Se encontró evidencia de certeza baja de que las intervenciones psicológicas iniciales de sesiones múltiples pueden estar asociadas con una tasa de abandono mayor que otras intervenciones psicológicas.

‐ Se encontró evidencia de certeza baja de que las intervenciones psicológicas iniciales de sesiones múltiples pueden ser ni más ni menos efectivas que otras intervenciones psicológicas para diagnosticar el TEPT; reducir la gravedad del TEPT, la depresión y la ansiedad; o mantener la funcionalidad general de los participantes que reciben la intervención.

• No se encontraron estudios que midieran los efectos adversos.

• No se encontraron estudios que midieran el uso de recursos relacionados con la salud.

¿Qué debe suceder a continuación?

La base de evidencia actual es pequeña. Sin embargo, se están realizando nuevos estudios y las futuras actualizaciones de esta revisión incorporarán los resultados de los mismos.

Conclusiones de los autores

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Implicaciones para la práctica

Estos resultados sugieren que en este momento hay evidencia muy limitada para apoyar la implementación de la intervención psicológica para el uso sistemático después de eventos traumáticos. Se encontró cierta evidencia contradictoria en cuanto al uso de los diarios de cuidados intensivos en las unidades de cuidados intensivos y cierta evidencia que sugiere un beneficio de los enfoques basados en la terapia cognitivo‐conductual (TCC) diádica breve y la intervención autoguiada basada en Internet, aunque no se consideró que la evidencia disponible fuera lo suficientemente sólida como para recomendar el uso regular de estas intervenciones sin evaluación adicional.

Implicaciones para la investigación

El número de estudios en curso representa que ésta es un área de investigación en rápida evolución. Las actualizaciones futuras de esta revisión incorporarán los resultados de estos estudios actualmente en curso. Otros ensayos controlados aleatorios bien diseñados de las intervenciones que parecían prometedoras podrían ser sometidos a una evaluación adicional (p.ej. Brunet 2013; Jones 2010; Kazak 2005; Mouthaan 2013). Sin embargo, puede suceder que estas intervenciones demuestren un mayor efecto cuando son dirigidas a individuos sintomáticos (Roberts 2010), debido a que muchos se recuperarán gradualmente sin necesidad de ninguna intervención (Bryant 2013). Se observa que las intervenciones cognitivo‐conductuales preventivas no se han investigado de forma adecuada. Sin embargo, la ausencia de efecto para las terapias breves individuales de procesamiento del trauma, que comparten algunas características con las terapias cognitivo‐conductuales centradas en el trauma, sugiere que los modelos que no están dirigidos a los pacientes con síntomas de estrés traumático pueden no ser el medio más fructífero de implementación de la intervención. La evidencia actual favorece los enfoques que centran la intervención en los pacientes que presentan síntomas o que han sido diagnosticados con trastorno de estrés agudo o trastorno por estrés postraumático (TEPT) agudo (Roberts 2010). Debido a los hallazgos positivos de la terapia diádica breve, sería interesante evaluar las formas de intervención familiar y comunitaria y las intervenciones dirigidas a mejorar las habilidades de afrontamiento y a mejorar los comportamientos positivos y útiles (Ruzek 2007). Las intervenciones basadas en Internet y en aplicaciones ofrecen potencialmente formas relativamente económicas y accesibles de ofrecer intervenciones a un gran número de personas y deben investigarse más a fondo. Los hallazgos de Mouthaan 2013 demuestran cierto apoyo a este enfoque y existen ahora varios estudios que han demostrado la efectividad de la TCC basada en Internet para el TEPT (Lewis 2018). Las investigaciones futuras también deben explorar el momento óptimo para intervenir, considerar los eventos adversos, la tolerabilidad del tratamiento y controlar cuidadosamente las intervenciones adicionales.

Summary of findings

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Summary of findings for the main comparison. Any early psychological intervention compared to waiting list/usual care for the prevention of post‐traumatic stress disorder

Any early psychological intervention compared to waiting list/usual care for the prevention of post‐traumatic stress disorder
Patient or population: various Setting: various Intervention: any early psychological intervention Comparison: waiting list/usual care
Outcomes	№ of participants (studies)	Certainty of the evidence (GRADE)	Relative effect (95% CI)	*Anticipated absolute effects (95% CI)**
				Risk with waiting list/usual care	Risk difference with any early psychological intervention
PTSD diagnosis: post‐treatment	556 (5 RCTs)	⊕⊝⊝⊝ Very low^a,b	RR 1.06 (0.85 to 1.32)	Study population
				283 per 1000	17 more per 1000 (42 fewer to 91 more)
PTSD diagnosis: 3–6 months	758 (5 RCTs)	⊕⊕⊝⊝ Low^c,d	RR 0.62 (0.41 to 0.93)	Study population
				215 per 1000	82 fewer per 1000 (127 fewer to 15 fewer)
PTSD diagnosis: 7–12 months	132 (1 RCT)	⊕⊝⊝⊝ Very low^e,f	RR 0.94 (0.20 to 4.49)	Study population
				47 per 1000	3 fewer per 1000 (38 fewer to 164 more)
Dropouts from treatment	1154 (11 RCTs)	⊕⊕⊝⊝ Low^d,k	RR 1.34 (0.91 to 1.95)	Study population
				125 per 1000	43 more per 1000 (11 fewer to 119 more)
Severity of PTSD symptoms: 3–6 months	1921 (15 RCTs)	⊕⊕⊝⊝ Low^g,h	—	The mean severity of PTSD symptoms: 3–6 months was 0	SMD 0.1 lower (0.22 lower to 0.02 higher)
Severity of depressive symptoms: 3–6 months	1009 (7 RCTs)	⊕⊕⊝⊝ Low^g,i	—	The mean severity of depressive symptoms at 3–6 months was 0	SMD 0.04 lower (0.19 lower to 0.1 higher)
Severity of anxiety symptoms: 3–6 months	945 (6 RCTs)	⊕⊕⊝⊝ Low^g,j	—	The mean severity of anxiety symptoms at 3–6 months was 0	SMD 0.05 lower (0.19 lower to 0.10 higher)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; PTSD: post‐traumatic stress disorder; RCT: randomised controlled trial; RR: risk ratio; SMD: standardised mean difference.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aThree of the five studies were at high risk of bias (Brunet 2013; Mouthaan 2013; Rothbaum 2012). ^bDowngraded two levels for imprecision as the total number of events was fewer than 300 and 95% CI included both little or no effect. ^cThree of the five studies were at high risk of bias (Jones 2010; Mouthaan 2013; Rothbaum 2012). ^dDowngraded one level for imprecision as the total number of events was fewer than 300. ^eThe study was at high risk of bias (Mouthaan 2013). ^fDowngraded two levels as the total number of events was fewer than 300 and 95% CI included both little or no effect. ^gDowngraded one level for imprecision as the 95% CI includes both little or no effect. ^hTwelve of the 15 studies were at high risk of bias (Als 2015; Borghini 2014; Brom 1993; Brunet 2013; Curtis 2016; Holmes 2007; Jensen 2016; Jones 2010; Kazak 2005; Mouthaan 2013; Rothbaum 2012; Zatzick 2001). ⁱSix of the seven studies were at high risk of bias (Als 2015; Curtis 2016; Holmes 2007; Jensen 2016; Mouthaan 2013; Zatzick 2001). ^jFive of the six studies were at high risk of bias (Als 2015; Curtis 2016; Jensen 2016; Kazak 2005; Mouthaan 2013). ^kEight of the 11 studies were at high risk of bias (Brom 1993; Brunet 2013; Holmes 2007; Kazak 2005; Rothbaum 2012; Ryding 1998; Ryding 2004; Zatzick 2001).

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Summary of findings 2. Any early psychological intervention compared to active control condition for the prevention of post‐traumatic stress disorder

Any early psychological intervention compared to active control condition for the prevention of post‐traumatic stress disorder
Patient or population: various Setting: various Intervention: any early psychological intervention Comparison: active control condition
Outcomes	№ of participants (studies)	Certainty of the evidence (GRADE)	Relative effect (95% CI)	*Anticipated absolute effects (95% CI)**
				Risk with active control condition	Risk difference with any early psychological intervention
Dropouts from treatment	425 (2 RCTs)	⊕⊕⊝⊝ Low^e,f	RR 1.61 (1.11 to 2.34)	Study population
				168 per 1000	103 more per 1000 (19 more to 225 more)
Severity of PTSD symptoms: 3–6 months	465 (4 RCTs)	⊕⊕⊝⊝ Low^c,d	—	The mean severity of PTSD symptoms at 3–6 months was 0	SMD 0.02 lower (0.31 lower to 0.26 higher)
Severity of depressive symptoms: 3–6 months	409 (2 RCTs)	⊕⊕⊝⊝ Low^d,e	—	The mean severity of depressive symptoms at 3–6 months was 0	SMD 0.04 higher (0.16 lower to 0.23 higher)
Severity of anxiety symptoms: 3–6 months	414 (2 RCTs)	⊕⊕⊝⊝ Low^d,e	—	The mean severity of anxiety symptoms at 3–6 months was 0	SMD 0 (0.19 lower to 0.19 higher)
General functioning: 3–6 months	239 (1 RCT)	⊕⊕⊝⊝ Low^g,h	—	The mean general functioning at 3–6 months was 0	MD 0.03 lower (0.06 lower to 0)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; MD: mean difference; PTSD: post‐traumatic stress disorder; RCT: randomised controlled trial; RR: risk ratio; SMD: standardised mean difference.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aStudy was at high risk of bias (Gidron 2001). ^bDowngraded two levels for imprecision as total number of events was fewer than 300 and 95% CI included both little or no effect. ^cAll four studies were at high risk or bias (Cox 2018a; Gamble 2010; Gidron 2001; Gidron 2007). ^dDowngraded one level for imprecision as 95% CI included both little or no effect. ^eBoth studies were at high risk of bias (Cox 2018a; Gamble 2010). ^fDowngraded one level for imprecision as total number of events was fewer than 300. ^gStudy was at high risk of bias (Gamble 2010). ^hDowngraded one level for imprecision as total number of participants was fewer than 400.

Antecedentes

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Descripción de la afección

En la actualidad existe una gran cantidad de literatura que demuestra que la experiencia traumática puede causar dificultades psicológicas significativas para un gran número de personas, a través de eventos tales como los desastres naturales (p.ej. Berger 2012; Schulz 2013), los desastres provocados por el hombre (p.ej. Jenkins 2012), los combates militares (Brunet 2015; Richardson 2019; Stevelink 2018), las violaciones (Dworkin 2017), los crímenes violentos (p.ej. Lowe 2017; Wilson 2015) y los accidentes de tráfico (Heron‐Delaney 2013). Muchos individuos muestran gran resiliencia frente a dichas experiencias y manifestarán reacciones de estrés de corta duración o subclínicas que disminuyen con el tiempo, aunque algunos experimentarán un retraso en la aparición de los síntomas (Bryant 2013). La mayoría de los pacientes se recupera sin atención médica ni psicológica (McNally 2003). Sin embargo, es posible que se desarrollen trastornos psicológicos en personas que estuvieron expuestas a un trauma. Los mismos incluyen reacciones depresivas, fóbicas y otros trastornos de ansiedad, abuso del alcohol u otras sustancias y, con menos frecuencia, trastorno obsesivo compulsivo, reacciones psicóticas y síntomas de conversión. Algunos individuos presentan síntomas compatibles con el trastorno de estrés agudo (TEA) en la primera fase después de un evento traumático. El trastorno de estrés postraumático (TEPT) es uno de los problemas de salud mental duraderos más frecuentes y que probablemente recibe más atención en la bibliografía de investigación.

El TEPT es definido por el Diagnostic and Statistical Manual 5t Edition (DSM5) como un síndrome que se compone de cuatro grupos de síntomas: reexperimentación repetida del trauma; evitación de los recordatorios internos y externos; alteraciones negativas en la cognición y el estado de ánimo; y alteraciones en la excitación y reactividad (APA 2013). Para que se pueda llevar a cabo un diagnóstico de TEPT, los síntomas tienen que haber estado presentes por más de un mes. El Diagnostic and Statistical Manual 4th Edition (DSM‐IV) usó el término "TEPT agudo" para describir el TEPT que comienza antes de los tres meses (APA 1994). Aunque este término ya no se utiliza en el DSM5 los primeros tres meses siguen siendo considerados como el período prioritario para la intervención inicial. Las tasas informadas de TEPT que comienza en los 12 meses varían entre las diferentes poblaciones expuestas al trauma, con una prevalencia estimada entre los estudios de alrededor del 29% un mes después del trauma y del 17% a los 12 meses (Santiago 2013). Las tasas de prevalencia tienden a ser más altas para los pacientes que han experimentado traumas intencionales por sobre los traumas no intencionales (Santiago 2013). La investigación epidemiológica sugiere que alrededor del 40% de los pacientes que desarrollan TEPT de aparición temprana desarrollan un trastorno crónico (Santiago 2013). La repercusión sobre la funcionalidad social, interpersonal y ocupacional de los pacientes que padecen TEPT crónico puede ser muy significativa a lo largo de la vida (Litz 2004; Kearns 2012).

Descripción de la intervención

Hasta la fecha, las revisiones Cochrane han considerado la intervención psicológica del TEPT (Bisson 2013) y el tratamiento farmacológico del TEPT (Stein 2006). Un gran número de ensayos controlados aleatorios (ECA) han demostrado la efectividad de algunas intervenciones psicológicas para el tratamiento del TEPT crónico (Bisson 2013; NICE 2018). La terapia cognitivo‐conductual centrada en el trauma (TCC; ver Bisson 2013; Bradley 2005) y la desensibilización y reprocesamiento del movimiento ocular (DRMO) (NICE 2018), tienen la base de evidencia más sólida. Las intervenciones basadas en la evidencia no son efectivas para todos, y muchos pacientes siguen presentando síntomas, incluso después de completar el tratamiento (Bradley 2005).

Desde los años noventa, los médicos han intentado cada vez más desarrollar intervenciones que puedan mitigar los efectos del trauma y prevenir la aparición del TEPT crónico. Durante varios años las intervenciones con sesiones únicas como el informe psicológico fueron una forma de intervención popular utilizada ampliamente. El informe psicológico se ha examinado en detalle durante los años noventa y fue el tema de una revisión Cochrane publicada en 1998 y actualizada posteriormente (Rose 2002). Otras revisiones informaron de hallazgos similares (van Emmerik 2002; Bastos 2015). La falta de evidencia sobre la eficacia del informe psicológico individual de sesión única ha dado lugar a que muchos expertos en el área sean cautelosos en cuanto a su uso (p.ej. NICE 2018).

De qué manera podría funcionar la intervención

La atención se dirige cada vez más a otros modelos de intervención (Kearns 2012; Qi 2016). Estos modelos han incluido intervenciones con sesiones múltiples dirigidas a individuos expuestos a un evento traumático con la intención de prevenir el desarrollo de TEPT, intervenciones para individuos con un factor de riesgo conocido o presunto e intervenciones específicas para individuos claramente sintomáticos. Por ejemplo, los primeros auxilios psicológicos se han prescrito cada vez más como una forma inicial de intervención (NCTSN/NCP 2006). Los primeros auxilios psicológicos se refieren a brindar consuelo, información, apoyo y asistencia a las necesidades inmediatas prácticas y emocionales. Las formas breves del TCC, proporcionadas alrededor de las dos semanas después del incidente, se han propuesto como intervenciones para prevenir el inicio del TEPT y para tratar a los pacientes que presentan síntomas en las primeras etapas después de un trauma. Además, se han indicado intervenciones dirigidas a mejorar el apoyo social (Litz 2002; Ormerod 2002). Se han realizado varios estudios para evaluar algunas de estas formas de intervención.

Por qué es importante realizar esta revisión

Algunos expertos en el área (p.ej. Bisson 2003; Brewin 2008; Qi 2016) abogan por intervenciones dirigidas a aquellos que están en mayor riesgo de continuar con la dificultad psicológica. Sin embargo, en las secuelas inmediatas de un evento traumático a menudo existe un imperativo fuerte de los servicios de asistencia sanitaria, el público y los políticos de proporcionar intervención psicológica a todas las personas que estuvieron expuestas, independientemente de la sintomatología. Aún es motivo de debate a quién se le debe ofrecer la intervención, el momento y la forma de la misma. Anteriormente se publicó una revisión Cochrane de las intervenciones psicológicas iniciales de sesiones múltiples para la prevención del TEPT (Roberts 2009) en que se encontraron 11 estudios de las intervenciones psicológicas breves dirigidas a la prevención del TEPT en individuos expuestos a un evento traumático específico. No se encontró evidencia que apoye el uso de estas intervenciones. En una segunda revisión, se encontró evidencia para la TCC centrada en el trauma sobre un control en lista de espera y sobre el asesoramiento de apoyo para los pacientes que presentaban síntomas de estrés traumático (Roberts 2010). La evidencia fue más sólida cuando los individuos cumplieron con el diagnóstico de TEA o TEPT agudo. Esta revisión tiene como objetivo aclarar la base de evidencia actual mediante una revisión actualizada de las intervenciones iniciales con sesiones múltiples dirigidas a la prevención del TEPT en individuos que estuvieron expuestos a un evento traumático, pero en los que no se identificaron dificultades psicológicas específicas.

Objetivos

disponible en

Métodos

disponible en

Criterios de inclusión de estudios para esta revisión

Tipos de estudios

ECA. No se utilizaron el tamaño de muestra, el idioma o el estado de la publicación para determinar si los estudios debían ser incluídos.

Tipos de participantes

Cualquier adulto de 18 años o más, expuesto a un evento traumático. Cuando un estudio incluyó a participantes adultos y adolescentes combinados, se intentó obtener datos separados para los adultos cuando los mismos estaban disponibles. Cuando estos datos no estaban disponibles, se requirió que al menos el 80% de la muestra tuviera 18 años de edad o más para incluir el estudio. Para los fines de esta revisión, un evento se consideró traumático si cumplió el criterio A1 de la DSM‐IV para el TEPT (APA 1994). Por lo tanto, se consideró que la mayoría de los participantes en los estudios incluidos habían presentado, presenciado o enfrentado un evento o eventos que incluyeron muerte real o amenaza o lesiones graves o una amenaza para la integridad física de uno mismo o de otras personas.

Se excluyeron los estudios que incorporaron a participantes con un determinado perfil de síntomas (p.ej. TEA, TEPT agudo, depresión) o que incorporaron a los participantes sobre la base de las respuestas a una medida de cribado.

Tipos de intervenciones

Esta revisión consideró cualquier intervención psicológica inicial con sesiones múltiples diseñada para prevenir los síntomas de estrés traumático y que comenzó dentro de los tres meses de un incidente traumático. Se excluyeron las intervenciones con sesiones únicas debido a que son el tema de otra revisión Cochrane (Rose 2002). Las intervenciones psicológicas iniciales dirigidas al tratamiento de los individuos que se identificaron como sintomáticos (p.ej. con TEA o TEPT agudo) son el tema de otra revisión (Roberts 2010) realizada al mismo tiempo que esta revisión.

Para esta revisión, una intervención psicológica incluyó cualquier intervención no farmacológica específica con el objetivo de prevenir la aparición del TEPT, implementada por uno o más profesionales de la salud o individuos no profesionales, con contacto entre el terapeuta y el participante en al menos dos ocasiones. Se decidió a priori que las categorías de intervención elegibles incluirían formas de tratamiento psicológico basadas en un modelo teórico especificado. Las categorías de intervención potenciales fueron identificadas a partir de revisiones previas basadas en el TEPT (Bisson 2013; NICE 2018). Estos resultados eran:

terapia cognitivo‐conductual centrada en el trauma (TCCCT): cualquier intervención psicológica que utilizara principalmente técnicas cognitivas, conductuales o cognitivo‐conductuales centradas en el trauma. Esta categoría incluyó la terapia de exposición;
control del estrés/relajación ‐ cualquier intervención psicológica que enseñara predominantemente técnicas de relajación o de control de la ansiedad/estrés;
terapia grupal de TCCCT ‐ cualquier enfoque administrado en un contexto grupal que predominantemente utilizara técnicas cognitivas, conductuales o cognitivo‐conductuales centradas en el trauma;
TCC ‐ cualquier intervención psicológica que utilizara predominantemente técnicas cognitivas, conductuales o cognitivo‐conductuales no centradas en el trauma. Esta categoría excluye la terapia de exposición;
DRMO ‐ cualquier intervención psicológica que utilizara predominantemente la DRMO;
terapia grupal con TCC no centrada en el trauma: cualquier enfoque administrado en un grupo que predominantemente utilizara técnicas cognitivas, conductuales o cognitivo‐conductuales no centradas en el trauma;
otra intervención psicológica ‐ cualquier intervención psicológica que utilizara predominantemente técnicas no centradas en el trauma que no se considerarían cognitivas, conductuales ni cognitivo‐conductuales. Esta categoría incluyó el asesoramiento no directivo, el tratamiento psicodinámico y la hipnoterapia.

Además, se decidió a priori que las intervenciones elegibles incluirían intervenciones no farmacológicas que no se basaron o que sólo se basaron parcialmente en un modelo teórico específico, pero que, no obstante, intentaran reducir los síntomas de estrés traumático para incluir las siguiente categorías.

Intervención que proporciona educación o información ‐ cualquier intervención que predominantemente sólo proporcionara educación o información acerca de posibles dificultades futuras y que ofreciera asesoramiento sobre medios constructivos de afrontamiento, o ambos.
Atención gradual ‐ cualquier plan de atención especificado a priori que ofreciera una intervención con atención gradual sobre la base de las necesidades continuas de los participantes incluidos.
Intervenciones dirigidas a mejorar las habilidades de afrontamiento positivas y a mejorar el bienestar general ‐ cualquier intervención no farmacológica que procurara mejorar el bienestar como una intervención de terapia ocupacional, una intervención con ejercicios o una intervención guiada de autoayuda.

Se decidió a priori que los ensayos considerados incluirían:

intervención psicológica versus lista de espera o control de atención habitual;
intervención psicológica versus otra intervención psicológica.

Del conocimiento previo de la bibliografía se sabía con claridad que se habían evaluado diversas formas de intervención en grupos de participantes diferentes. Se consideró que varios estudios habían ofrecido intervención a todos los individuos expuestos. Se sabía que otros habían evaluado intervenciones para los que cumplían los criterios de inclusión según variables predictivas de riesgo futuro. Se decidió realizar la comparación de todas las intervenciones juntas inicialmente y realizar un subanálisis de las intervenciones específicas y las intervenciones dirigidas a individuos con factores de riesgo específicos, de ser apropiado.

Tipos de medida de resultado

Resultados primarios

Tasas de TEPT entre los pacientes expuestos a un trauma medidas con un sistema de clasificación estándar, evaluadas mediante una medida estandarizada como la Clinician‐Administered PTSD Scale (CAPS; Blake 1995).
Abandono del tratamiento.

Resultados secundarios

Gravedad de los síntomas de estrés traumático utilizando una medida estandarizada como la CAPS (Blake 1995), la Impact of Event Scale (Horowitz 1979), la Davidson Trauma Scale (Davidson 1997), o la Post‐traumatic Diagnostic Scale (Foa 1995). En las circunstancias en las que un estudio individual utilizó tanto una medida administrada por el médico como una medida informada por el participante, se dio prioridad a los resultados utilizando la medida administrada por el médico, debido a que se considera que dichas medidas proporcionan el "estándar de referencia" en el área del estrés traumático (p.ej. Foa 1997).
Gravedad de los síntomas depresivos informada por el participante mediante una medida estandarizada como el Beck Depression Inventory (Beck 1961).
Gravedad de los síntomas de ansiedad informada por el participante utilizando una medida estandarizada como el Beck Anxiety Inventory (Beck 1988), o el Spielberger State‐Trait Anxiety Inventory (Spielberger 1970)
Efectos adversos
Funcionalidad general que incluye las medidas de la calidad de vida como el 36‐item Short Form (SF‐36; Ware 1993).
Uso de recursos sanitarios.

Se realizaron sólo las comparaciones con datos de seguimiento cuando los datos de resultados correspondían a puntos temporales similares. Estos puntos temporales se decidieron a priori como postratamiento, tres a seis meses postrauma, siete a 12 meses postrauma, uno a dos años postrauma, dos años y más de dos años. El período de resultados primarios fue de tres a seis meses después del trauma.

Métodos de búsqueda para la identificación de los estudios

Búsquedas electrónicas

Cochrane Common Mental Disorders Controlled Trials Register (CCMD‐CTR)

The Cochrane Common Mental Disorders (CCMD) Group maintains a specialised register of RCTs, the CCMD‐CTR. This register contains over 40,000 reference records (reports of RCTs) for anxiety disorders, depression, bipolar disorder, eating disorders, self‐harm and other mental disorders within the scope of this Group. The CCMD‐CTR is a partially studies‐based register with more than 50% of reference records tagged to approximately 12,500 individually PICO‐coded study records. Reports of trials for inclusion in the register are collated from (weekly) generic searches of MEDLINE (from 1950), Embase (from 1974) and PsycINFO (from 1967); quarterly searches of the Cochrane Central Register of Controlled Trials (CENTRAL), and review specific searches of additional databases. Reports of trials are also sourced from international trial registries, drug companies, the handsearching of key journals, conference proceedings, and other (non‐Cochrane) systematic reviews and meta‐analyses. Details of CCMD's core search strategies (used to identify RCTs) can be found on the Group's website, with an example of the core MEDLINE search displayed in Appendix 1. The CCMD‐CTR fell out of date in June 2016, with the move of the editorial base from the University of Bristol to York.

Searches for this review were conducted in August 2008, May 2016 and March 2018.

Search one (1 August 2008)

CCMDCTR‐Studies: Diagnosis = "stress disorder*" or PTSD and Intervention = therapy or intervention or counsel* or debriefing and Age‐group = adult or aged or "not stated" or unclear and not Duration of therapy = "1 session"

CCMDCTR‐References: Keyword = "Stress Disorder*" or "Stress‐Disorder*" or Free‐text = PTSD and Free‐text = debrief* or *therap* or intervention* or counsel*

Search two (6 May 2016)

CCMDCTR‐Studies Register: (PTSD or posttrauma* or post‐trauma* or "post trauma*" or "combat disorder*" or "stress disorder*"):sco,stc

CCDMDCTR‐References Register: (PTSD or posttrauma* or post‐trauma* or "post trauma*" or "combat disorder*" or "stress disorder*"):ti,ab,kw,ky,emt,mh,mc
[Key to field tags. ti:title; ab:abstract; kw:keywords; ky:other keywords; mh:MeSH headings; mc:MeSH check words; emt:EMTREE headings; sco:healthcare condition; stc:target condition]

Search three (3 March 2018)

CCMD's information specialist conducted additional searches on the following bibliographic databases, using relevant subject headings (controlled vocabularies) and search syntax, appropriate to each resource.

The search was for a suite of PTSD reviews and the search terms were based on population or psychological debriefing (Appendix 2).

The Cochrane Central Register of Controlled Trials (CENTRAL), Issue 2 of 12, February 2018;
Ovid MEDLINE (2014 to 3 March 2018);
Ovid Embase (2014 to 3 March 2018);
Ovid PsycINFO (2014 to 3 March 2018);
Ebsco PILOTS (2014 to 3 March 2018).

Search four (15 March 2019)

In keeping with MECIR conduct standard c37 (searches to be within 12 months of publication), we ran an update search in March 2019. We screened the abstracts and placed any new trials matching our inclusion criteria as 'awaiting classification'. These will be incorporated into the next version of this review, as appropriate.

Búsqueda de otros recursos

Reference lists

We searched reference lists of the National Institute for Health and Care Excellence PTSD guidelines (NICE 2018), and studies identified in the search and of related review articles.

Personal communication

We provided a list of included references on the website of the International Society for Traumatic Stress Studies and contacted the membership to ask them to identify any studies that they thought might be missing.

Obtención y análisis de los datos

Selección de los estudios

Two review authors (NR and CL) independently read the abstracts of all potential trials. If an abstract appeared to represent an RCT, each review author independently read the full report to determine if the trial met the inclusion criteria. When agreement could not be reached about inclusion, we consulted a third review author. The studies excluded on further reading are listed in the Characteristics of excluded studies table, with reasons for their exclusion.

Extracción y manejo de los datos

We designed a data extraction sheet to capture data that was entered into Review Manager 5 software (Review Manager 2014). Information extracted included demographic details of participants, details of the traumatic event, the randomisation process, the interventions used, dropout rates and outcome data. Two review authors (of NR, NK and JK) independently extracted data. When agreement could not be reached, we discussed the issue a third review author.

Evaluación del riesgo de sesgo de los estudios incluidos

Two review authors (of NR, NK and JK) independently assessed the risk of bias for each study, using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions and listed below (Higgins 2011). We resolved conflicts through discussion with a third review author (JB).

Random sequence generation.
Allocation concealment.
Blinding of outcome assessment.
Incomplete outcome data.
Selective outcome reporting.
Other bias (including baseline imbalances, early termination of the trial, researcher allegiance).

We did not assess blinding of participants and personnel as a double‐blind methodology for studies of psychological treatment is impossible as it is clear to participants what treatment they are receiving.

We judged each potential source of bias as high, low or unclear, and provided a supporting quotation from the study report, together with a justification for the judgement, in the 'Risk of bias' table. We summarised risk of bias judgements across different studies for each of the domains listed. We considered blinding separately for different key outcomes when necessary. When information on risk of bias related to unpublished data or correspondence with a trialist, we noted this in the 'Risk of bias' table.

When considering treatment effects, we took into account risk of bias for studies that contributed to that outcome.

Medidas del efecto del tratamiento

Continuous data

We analysed continuous outcomes using mean difference (MD) when all trials had measured outcome on the same scale. When trials measured outcomes on different scales, we used the standardised mean difference (SMD).

Dichotomous data

We used the risk ratio (RR) as the main categorical outcome measure as this is more widely used than odds ratio (OR) in health‐related practice. All outcomes were presented using 95% confidence intervals (CI).

Cuestiones relativas a la unidad de análisis

For trials which had a crossover design, we considered only results from the first randomisation period. If the trial was a three (or more) armed trial, consideration was given to undertaking pair‐wise meta‐analysis with each arm, depending upon the nature of the intervention in each arm and the relevance to the review objectives. Management of cluster randomised trials followed guidance provided in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

Manejo de los datos faltantes

When intention‐to‐treat (ITT) data were available, we reported these in the results. We attempted to access ITT data wherever possible. We used completer‐only data when this was the only type of data available. In cases where there was inadequate information within a particular paper to undertake analysis, we attempted to compute missing data from other information available within the paper, using guidance provided in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). For example, we calculated standard deviations (SDs) for continuous data when only the standard error (SE) or t statistics or P values were reported. When imputation was not possible or when further clarification was required, we attempted to contact the authors to request additional information. In cases where no further useable data were available, the study was not included in further analysis.

Evaluación de la heterogeneidad

We used a visual inspection of the forest plots initially to explore for possible statistical heterogeneity (variation in intervention effects or results). We measured heterogeneity between studies by observing the I² test and the Chi² test (P < 0.10). An I² of less than 30% was considered to indicate that statistical heterogeneity might not be important; an I² of 30% to 60% to indicate moderate heterogeneity; an I² of 50% to 90% to indicate substantial heterogeneity and an I² greater than 75% to indicate considerable heterogeneity. Clinical and methodological heterogeneity reflect issues such as differences in participant populations, intervention types, study design and methodological rigour. We anticipated that included studies would evaluate a range of different interventions in a wide variety of populations. Therefore, we used a random‐effects model for all comparisons.

Evaluación de los sesgos de notificación

It was decided a priori that if a minimum of 10 studies were available in a meta‐analysis, we would prepare funnel plots and examine them for signs of asymmetry. Where there was asymmetry, we planned to consider other possible reasons for this.

Síntesis de los datos

We pooled data from more than one study using a fixed‐effect model, except where heterogeneity was considered to be present. In these cases, we used a random‐effects model as described below.

Análisis de subgrupos e investigación de la heterogeneidad

It was decided a priori that we would explore the following possible causes of clinical heterogeneity if sufficient data allowed.

Number of treatment sessions taken (two to six versus seven or more).
Type of traumatic event (combat‐related trauma versus rape and sexual assault versus other civilian trauma).
Participant characteristics (men versus women)

Análisis de sensibilidad

It was decided a priori that sensitivity analysis would explore possible causes of methodological heterogeneity if sufficient data allowed. Analysis would be based on the following criteria.

Trials considered most susceptible to bias would be excluded based on the following quality assessment criteria:
1. those with unclear allocation concealment;
2. high levels of postrandomisation losses (more than 40%) or exclusions;
3. unblinded outcome assessment or blinding of outcome assessment uncertain.
Use of ITT analysis versus completer outcomes would be undertaken depending on available data.

'Summary of findings' tables

We evaluated the certainty of available evidence using the GRADE approach. We generated 'Summary of findings' tables using GRADEpro GDT software, which imports data from Review Manager 5 (GRADEpro GDT; Review Manager 2014). These tables provided outcome‐specific information concerning the overall certainty of evidence from studies included in the comparison, the magnitude of effect of the interventions examined and the sum of available data on outcomes considered. We included information on the first seven outcomes of our review: PTSD diagnosis (on a clinician‐administered scale), severity of traumatic stress symptoms, severity of self‐reported depressive symptoms, severity of self‐reported anxiety symptoms, dropouts, adverse effects and general functioning. For the primary outcome of PTSD diagnosis, we reported all time points available. For the secondary outcomes, we prioritised the primary end point of three to six months' postintervention.

We assessed the certainty of evidence using five factors.

Limitations in study design and implementation of available studies.
Indirectness of evidence.
Unexplained heterogeneity or inconsistency of results.
Imprecision of effect estimates.
Potential publication bias.

For each outcome, we classified the certainty of evidence according to the following categories.

High certainty : further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty : further research is likely to have an important impact on our confidence in the estimate of effect, and may change the estimate.
Low certainty : further research is very likely to have an important impact on our confidence in the estimate of effect, and is likely to change the estimate.
Very low certainty : we are very uncertain about the estimate.

We downgraded the evidence from high certainty by one level for serious (or by two for very serious) study limitations (risk of bias), indirectness of evidence, serious inconsistency, imprecision of effect estimates or potential publication bias.

Results

Description of studies

Results of the search

See Figure 1.

Figure 1

PRISMA flow diagram.

The search identified 7380 titles and abstracts and two review authors independently read 297 papers in detail to establish if they met the specified inclusion criteria.

An update search (15 March 2019) identified 781 RCT records. We screened the abstracts and have added 11 new studies to those awaiting classification.

Included studies

Twenty‐seven studies, including 11 identified in Roberts 2009, evaluated brief (two or more sessions) psychological interventions aimed at preventing PTSD in people exposed to a specific traumatic event. Twenty five studies were reported in English, one in French (Andre 1997), and one in Persian (Taghizadeh 2008). The studies are described in the Characteristics of included studies table.

Study design

All included studies were two armed RCTs, apart from one study (Lindwall 2014), which included three arms, one of which evaluated intervention offered to children which was not eligible for inclusion in this review. Participants would not have been blind to their allocation group. Sample size in the included studies varied from 17 (Gidron 2001) to 386 (Jensen 2016) participants. The total number of participants randomised in the 27 studies was 3963.

Participants

Seven studies were conducted in the USA (Biggs 2016; Cox 2018a; Curtis 2016; Kazak 2005; Lindwall 2014; Rothbaum 2012; Zatzick 2001); three in Canada (Brunet 2013; Irvine 2011; Marchand 2006); three in Australia (Gamble 2005; Gamble 2010; Holmes 2007); two in the Netherlands (Brom 1993; Mouthaan 2013); two in Israel (Gidron 2001; Gidron 2007); two in Sweden (Ryding 1998; Ryding 2004); one in France (Andre 1997); one in Iran (Taghizadeh 2008); one in the UK (Als 2015); one in Switzerland (Borghini 2014); one in Denmark (Jensen 2016); one in China (Wang 2015); one in Sri Lanka (Wijesinghe 2015); and one study was conducted in various European countries including Denmark, Italy, Norway, Portugal, Sweden and the UK (Jones 2010).

Five studies evaluated interventions offered to mothers who had experienced traumatic births (Gamble 2005; Gamble 2010; Ryding 1998; Ryding 2004; Taghizadeh 2008), while another study was of mothers of babies born at less than 33 weeks' gestation (Borghini 2014). Five studies included individuals who had been involved in road traffic accidents (Brom 1993; Gidron 2001; Gidron 2007; Wang 2015; Zatzick 2001). In four studies, participants were family members (Als 2015; Curtis 2016; Kazak 2005; Lindwall 2014): one study was in relatives of patients admitted to an intensive care unit (Curtis 2016), one was in parents whose child was newly diagnosed with cancer (Kazak 2005), one was in parents whose child received a stem cell or bone marrow transplant (Lindwall 2014), and one was in parents of a child admitted to a paediatric intensive care unit (Als 2015). Three studies were in individuals who had experienced major physical trauma and had been admitted to a trauma centre (Holmes 2007; Mouthaan 2013; Rothbaum 2012), while another three were in individuals who had been admitted to an intensive care unit (Cox 2018a; Jensen 2016; Jones 2010). One study included individuals who had been exposed to armed robbery, involving acts of violence (Marchand 2006). Participants in this study had to have reported experiencing intense fear, helplessness or horror during or after the robbery for inclusion. One study was conducted in individuals who had been exposed to a life‐threatening event (Brunet 2013), one included bus drivers who had been assaulted (Andre 1997), one was in people who had received an implantable cardioverter defibrillator (ICD) (Irvine 2011), one was on military mortuary workers (Biggs 2016), and one was in snakebite victims (Wijesinghe 2015).

Interventions

Twenty‐one studies compared multiple session early interventions versus treatment as usual. Five studies used an approach which we grouped as "brief individual trauma processing" (Brom 1993; Gamble 2005; Marchand 2006; Rothbaum 2012; Ryding 1998). This subgroup consisted of a number of brief therapies – lasting two or more sessions – that were theoretically diverse but shared similar core treatment components. These included: psychoeducation, therapist directed reliving of the index trauma to promote elaboration of the trauma memory and help to contextualise or reframe aspects of the experience. Two studies used CBT (Andre 1997; Irvine 2011), two used brief dyadic CBT (therapy involving a trauma exposed individual in conjunction with a significant other person, such as a partner, spouse or other family member) (Brunet 2013; Kazak 2005), one used a self‐guided Internet‐based intervention (Mouthaan 2013), one used brief interpersonal therapy (IPT) (Holmes 2007), one used a counselling intervention (Taghizadeh 2008), one used group counselling (Ryding 2004), one used psychological first aid group sessions (Biggs 2016), one used collaborative care (Zatzick 2001), one used intensive care diaries (Jones 2010), one used three‐step early intervention (Borghini 2014), one used supported psychoeducation (Als 2015), one used communication facilitator in an intensive care setting (Curtis 2016), one used nurse‐led intensive care recovery programme (Jensen 2016), and one used creative art (Wang 2015).

Six studies compared a psychological intervention with another intervention. Two studies compared memory structuring intervention with supportive listening (Gidron 2001; Gidron 2007), one study compared CBT with an education programme (Cox 2018a), one study compared a resilience programme with parenting support (Gamble 2010), one study compared a child‐targeted intervention (massage and humour therapy) with child‐targeted plus a parent‐targeted (massage, relaxation, imagery) intervention (Lindwall 2014), and one compared psychological first aid and psychoeducation and CBT versus psychological first aid and psychoeducation (Wijesinghe 2015).

Further information about specific interventions is provided in the Characteristics of included studies table.

Outcomes

Most of the included studies used well validated self‐report measures of PTSD, depression or anxiety as key outcomes. Measures used are listed in the Characteristics of included studies table. The most commonly used tool for measuring PTSD was the Impact of Events Scale (IES) (Als 2015; Andre 1997; Brom 1993; Marchand 2006; Rothbaum 2012; Ryding 1998; Ryding 2004; Taghizadeh 2008), followed by the Impact of Event Scale – Revised (IES‐R) (Brunet 2013; Cox 2018a; Irvine 2011; Kazak 2005; Lindwall 2014; Mouthaan 2013; Wang 2015), Post‐Traumatic Stress Disorder Checklist (PCL) (Biggs 2016; Curtis 2016; Holmes 2007; Zatzick 2001), and CAPS (Brunet 2013; Mouthaan 2013; Wang 2015). Other PTSD scales used less commonly included the Mini‐International Neuropsychiatric Interview for PTSD (MINI‐PTSD) (Gamble 2005), Perinatal Posttraumatic Stress Disorder Questionnaire (PPQ) (Borghini 2014), Harvard Trauma Questionnaire (HTQ) (Jensen 2016), PTSD Symptom Scale – Interview Version (PSS‐I) (Rothbaum 2012), and Post‐traumatic Stress Symptom Scale – Self Report (PSS‐SR) (Wijesinghe 2015).

Other outcomes such as anxiety, depression and quality of life were measured using Hospital Anxiety and Depression Scale (HADS) (Als 2015; Andre 1997; Cox 2018a; Holmes 2007; Irvine 2011; Jensen 2016; Mouthaan 2013; Wang 2015), Patient Health Questionnaire (PHQ‐9) (Biggs 2016; Curtis 2016), SF‐36 (Holmes 2007; Irvine 2011; Jensen 2016; Mouthaan 2013), Generalised Anxiety Disorder Assessment (GAD‐7) (Curtis 2016), World Health Organization Quality of Life Assessment (Biggs 2016), Trauma Symptom Inventory (Brom 1993), Social Constraints Scale (SCS) (Brunet 2013), Social Adjustment Scale by Self‐Report (SAS‐SR) (Brunet 2013), EuroQol (EQ‐5D) (Cox 2018a), Patient‐Reported Outcomes Measurement Information System (PROMIS) (Cox 2018a), Brief Coping Orientation to Problems Experienced (COPE) (Cox 2018a), Edinburgh Postnatal Depression Scale (EPDS) (Gamble 2005; Gamble 2010; Ryding 2004), Depression Anxiety and Stress Scale‐21 (DASS‐21) (Gamble 2005; Gamble 2010), Maternity Social Support Scale (MSSS) (Gamble 2005), and health‐related quality of life (HRQoL) (Gamble 2010).

We used data from a clinician‐administered PTSD severity measure for six studies (Brunet 2013; Gamble 2005; Jones 2010; Marchand 2006; Mouthaan 2013; Rothbaum 2012). Data were only available from self‐report measures from17 trials (Als 2015; Borghini 2014; Brom 1993; Cox 2018a; Curtis 2016; Gamble 2010; Gidron 2001; Gidron 2007; Holmes 2007; Irvine 2011; Jensen 2016; Kazak 2005; Lindwall 2014; Ryding 1998; Ryding 2004; Taghizadeh 2008; Zatzick 2001).

Excluded studies

See Characteristics of excluded studies table.

In this update, we culled the list of excluded studies (previously reported in the first version of this review (Roberts 2009), to those studies which narrowly missed the inclusion criteria, those readers may plausibly expect to see included.

We excluded 38 studies following access of full‐text articles, as they did not satisfy the inclusion criteria. Of these, participants already had PTSD symptoms in 34 trials (Ben‐Zion 2018; Bisson 2004; Bryant 1998; Bryant 1999; Bryant 2003; Bryant 2005; Bryant 2008; Bugg 2009; Cernvall 2015; Echeburua 1996; Ehlers 2003; Foa 2006; Freedman (in preparation); Freedman (submitted); Freyth 2010; Jarero 2011; Jarero 2015; Nixon 2012; Nixon 2016; O'Donnell (in preparation); O'Donnell 2012; Öst unpublished; Shalev 2012; Shapiro 2015; Shapiro 2018; Shaw 2013; Sijbrandij 2007; Skogstad 2015; van Emmerik 2008; Wagner 2007; Wu 2014; Zatzick 2004; Zatzick 2013; Zatzick 2015). Four studies evaluated single session interventions (Resnick 2005; Rose 1999; Rothbaum (submitted); Turpin 2005).

Studies awaiting classification

One study could not be accessed and has been included in studies awaiting classification (Kilpatrick 1984). A further 11 newly completed studies were identified in the most recent search of March 2019 and are awaiting classification (see Characteristics of studies awaiting classification table).

Ongoing studies

For details of ongoing studies, see Characteristics of ongoing studies table.

Risk of bias in included studies

See Figure 2 and Figure 3.

Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Methodological quality of many of the included studies was poor. The process of recruitment used by Brom 1993 was of particular concern as recruitment took place prior to invitation to potential participants to join the study. This may lead to significant difference in response rate, dropout rate, other dropout factors and baseline scores between the treatment and control group.

Random sequence generation

Twelve studies provided an adequate description of the randomisation process and were at low risk of selection bias (Als 2015; Brunet 2013; Cox 2018a; Curtis 2016; Gamble 2005; Gamble 2010; Holmes 2007; Irvine 2011; Jensen 2016; Jones 2010; Mouthaan 2013; Rothbaum 2012). Twelve studies did not report the randomisation process and were therefore at unclear risk of selection bias (Andre 1997; Biggs 2016; Borghini 2014; Brom 1993; Gidron 2001; Gidron 2007; Kazak 2005; Lindwall 2014; Marchand 2006; Wang 2015; Wijesinghe 2015; Zatzick 2001). Three studies were at high risk of selection bias as the process was not truly random (Ryding 1998; Ryding 2004: Taghizadeh 2008). Ryding 2004 randomised women who gave birth on approximately 18 predetermined days of the month to the counselling group. Ryding 1998 selected every second emergency caesarean section patient, according to the delivery ward register, for counselling, the remainder were in the comparison group. Taghizadeh 2008 randomised participants by day of the week.

Allocation concealment

Twelve studies reported adequate concealment procedures and were at low risk of selection bias (Als 2015; Borghini 2014; Cox 2018a; Curtis 2016; Gamble 2005; Holmes 2007; Jensen 2016; Jones 2010; Kazak 2005; Mouthaan 2013; Rothbaum 2012; Zatzick 2001). In 12 studies, allocation concealment was unclear or inadequate (Andre 1997; Biggs 2016; Brom 1993; Brunet 2013; Gamble 2010; Gidron 2001; Gidron 2007; Irvine 2011; Lindwall 2014; Marchand 2006; Wang 2015; Wijesinghe 2015). Three studies made no attempt to hide allocation concealment and were at high risk of selection bias (Ryding 1998; Ryding 2004; Taghizadeh 2008).

Blinding of participants and personnel

This was not assessed as a double‐blind methodology for studies of psychological treatment is impossible as it is clear to participants what treatment they are receiving.

Blinding of outcome assessors

Seventeen studies blinded outcome assessors and were at low risk of detection bias (Als 2015; Cox 2018a; Curtis 2016; Gidron 2001; Gidron 2007; Holmes 2007; Irvine 2011; Kazak 2005; Marchand 2006; Mouthaan 2013; Rothbaum 2012; Ryding 1998; Ryding 2004; Taghizadeh 2008; Wang 2015; Wijesinghe 2015; Zatzick 2001). Seven studies did not report this (Andre 1997; Borghini 2014; Brunet 2013; Gamble 2005; Gamble 2010; Jensen 2016; Lindwall 2014), and three studies were at high risk of detection bias (Biggs 2016; Brom 1993; Jones 2010).

Incomplete outcome data

Ten studies fully reported loss to follow‐up and adequately dealt with missing outcome data (Brunet 2013; Cox 2018a; Gamble 2005; Irvine 2011; Jones 2010; Marchand 2006; Mouthaan 2013; Ryding 1998; Wang 2015; Zatzick 2001). Gamble 2005 included follow‐up data from all participants (one participant in the intervention group could not be contacted at initial follow‐up). Marchand 2006 and Zatzick 2001 included withdrawals in analysis by estimation of outcome by the method of 'last observation carried forward'. Thirteen studies did not adequately report missing outcome data and loss to follow‐up and were at high risk of bias (Als 2015; Andre 1997; Biggs 2016; Borghini 2014; Brom 1993; Curtis 2016; Gamble 2010; Gidron 2001; Gidron 2007; Holmes 2007; Jensen 2016; Kazak 2005; Lindwall 2014). Four studies provided data only for treatment completers and recorded withdrawals without reasons by group or the number of withdrawals was not specified and were at unclear risk of bias (Rothbaum 2012; Ryding 2004; Taghizadeh 2008; Wijesinghe 2015).

Selective reporting

Seven studies published protocols and reported on prespecified outcomes and were at low risk of reporting bias (Als 2015; Cox 2018a; Curtis 2016; Gamble 2010; Irvine 2011; Jensen 2016; Mouthaan 2013). Fourteen studies did not publish protocols and therefore it was unclear if they were free from reporting bias (Borghini 2014; Brom 1993; Brunet 2013; Gamble 2005; Gidron 2001; Holmes 2007; Jones 2010; Kazak 2005; Marchand 2006; Rothbaum 2012; Ryding 1998; Ryding 2004; Taghizadeh 2008; Zatzick 2001). One study did not report PTSD diagnosis as a primary outcome and was at high risk of reporting bias (Gidron 2007). Five other studies with null findings were at high risk of selective reporting because they did not provide data that could be used in meta‐analysis (Andre 1997; Biggs 2016; Lindwall 2014; Wang 2015; Wijesinghe 2015).

Other bias

Three studies were at low risk of other bias (Andre 1997; Lindwall 2014; Taghizadeh 2008). Nine studies were at unclear risk of other bias (Borghini 2014; Curtis 2016; Gamble 2005; Holmes 2007; Irvine 2011; Marchand 2006; Ryding 1998; Ryding 2004; Wijesinghe 2015). Fifteen studies were at high risk of other bias (Als 2015; Biggs 2016; Brom 1993; Brunet 2013; Cox 2018a; Gamble 2010; Gidron 2001; Gidron 2007; Jensen 2016; Jones 2010; Kazak 2005; Mouthaan 2013; Rothbaum 2012; Wang 2015; Zatzick 2001). Reasons for studies being judged at high risk of other bias include small sample size (Als 2015; Gidron 2001; Gidron 2007; Kazak 2005; Wang 2015; Zatzick 2001), inadequate description of the intervention (Biggs 2016), evaluation of treatment adherence not reported (Biggs 2016; Gidron 2001; Gidron 2007; Jensen 2016), differences in treatment groups at baseline (Brom 1993; Gamble 2010), study authors affiliated with intervention (Brunet 2013; Gidron 2001; Gidron 2007; Mouthaan 2013; Rothbaum 2012), higher‐than expected attrition rate (Cox 2018a), PTSD diagnosis based on assessor administration of PDS (Jones 2010) and intervention not manualised (Wang 2015; Zatzick 2001).

Effects of interventions

See: Summary of findings for the main comparison Any early psychological intervention compared to waiting list/usual care for the prevention of post‐traumatic stress disorder; Summary of findings 2 Any early psychological intervention compared to active control condition for the prevention of post‐traumatic stress disorder

The meta‐analyses included 21 studies with 2721 participants. Results were reported for all available outcome measures specified in the methodology. None of the studies identified reported data on adverse effects or use of health‐related resources. Six studies could not be used in the meta‐analysis as they reported no useable data (Andre 1997; Biggs 2016; Lindwall 2014; Taghizadeh 2008; Wang 2015; Wijesinghe 2015).

Comparison 1: any intervention versus waiting list/usual care

Twenty‐one studies compared a psychological intervention against a waiting list or treatment as usual condition (Als 2015; Andre 1997; Biggs 2016; Borghini 2014; Brom 1993; Brunet 2013; Curtis 2016; Gamble 2005; Holmes 2007; Irvine 2011; Jensen 2016; Jones 2010; Kazak 2005; Marchand 2006; Mouthaan 2013; Rothbaum 2012; Ryding 1998; Ryding 2004; Taghizadeh 2008; Wang 2015; Zatzick 2001).

Primary outcome

1. PTSD diagnosis

Six studies used a clinician‐administered scale to measure PTSD diagnosis and were entered into the meta‐analyses (Brunet 2013; Gamble 2005; Jones 2010; Marchand 2006; Mouthaan 2013; Rothbaum 2012). The remaining 15 studies used a self‐reported measure and were not included in the meta‐analyses (Als 2015; Andre 1997; Biggs 2016; Borghini 2014; Brom 1993; Curtis 2016; Holmes 2007; Irvine 2011; Jensen 2016; Kazak 2005; Ryding 1998; Ryding 2004; Taghizadeh 2008; Wang 2015; Zatzick 2001).

Post‐treatment

Five studies provided data on clinician‐administered diagnosis of PTSD (Brunet 2013; Gamble 2005; Marchand 2006; Mouthaan 2013; Rothbaum 2012). Post‐treatment there was a lack of evidence for difference between intervention and control conditions (RR 1.06, 95% CI 0.85 to 1.32; I² = 0%; studies = 5; participants = 556; very low‐certainty evidence; Analysis 1.1).

When analysed by type of psychological intervention, there was a lack of evidence for difference between treatment as usual and brief individual trauma processing therapy (RR 1.10, 95% CI 0.87 to 1.40; I² = 0%; studies = 3; participants = 262). There was uncertainty in estimating differences between treatment as usual and self‐guided Internet‐based interventions (RR 0.91, 95% CI 0.40 to 2.06; studies = 1; participants = 228), brief dyadic CBT (RR 0.59, 95% CI 0.21 to 1.61; studies = 1; participants = 66) reflected by the very wide confidence intervals.

Three to six months' follow‐up

Five studies provided data on clinician‐administered diagnosis of PTSD at three to six months' follow‐up (Gamble 2005; Jones 2010; Marchand 2006; Mouthaan 2013; Rothbaum 2012). Multiple session early psychological interventions were associated with a reduction in PTSD symptoms compared to treatment as usual (RR 0.62, 95% CI 0.41 to 0.93; I² = 34%; studies = 5; participants = 758; low‐certainty evidence; Analysis 1.2).

When analysed by type of intervention, meta‐analysis of three studies identified uncertainty for the difference between treatment as usual and brief individual trauma processing therapy reflected in the wide confidence interval (RR 0.73, 95% CI 0.44 to 1.22; I² = 41%; studies = 3; participants = 251). There was considerable imprecision in estimating the difference between self‐guided Internet‐based interventions and treatment as usual (RR 0.50, 95% CI 0.18 to 1.45; studies = 1; participants = 185). Evidence from one study of 322 participants showed that intensive care diaries were more effective than delayed access to diaries (RR 0.38, 95% CI 0.17 to 0.82).

Seven to 12 months' follow‐up

One study measured clinician‐administered PTSD at seven to 12 months' follow‐up (Mouthaan 2013). There was very high imprecision in estimating differences between self‐guided Internet‐based intervention and treatment as usual (RR 0.94, 95% CI 0.20 to 4.49; studies = 1; participants = 132; very low‐certainty evidence; Analysis 1.3).

2. Dropout from treatment

Eleven studies provided data on the number of participants who left the study early (Brom 1993; Brunet 2013; Gamble 2005; Holmes 2007; Irvine 2011; Kazak 2005; Marchand 2006; Rothbaum 2012; Ryding 1998; Ryding 2004; Zatzick 2001). Meta‐analysis indicated that there was no significant difference in dropouts (RR 1.34, 95% CI 0.91 to 1.95; I² = 34%; studies = 11; participants = 1154; low‐certainty evidence; Analysis 1.4).

When analysed by type of intervention, evidence from one study indicated brief IPT was associated with a higher dropout rate than TAU (RR 3.06, 95% CI 1.39 to 6.75; participants = 90). There was no significant difference, and wide confidence intervals, in the dropout rates between treatment as usual and brief individual trauma processing therapy (RR 1.06, 95% CI 0.67 to 1.68; I² = 26%; studies = 5; participants = 571), brief dyadic therapy (RR 2.09, 95% CI 0.76 to 5.75; I² = 0%; studies = 2; participants = 112), group therapy (RR 0.72, 95% CI 0.27 to 1.89; studies = 1; participants = 162), collaborative care (RR 0.75, 95% CI 0.14 to 3.94; studies = 1; participants = 34), or telephone‐based CBT (RR 2.42, 95% CI 0.79 to 7.44; studies = 1; participants = 185).

Secondary outcomes

1. Severity of PTSD symptoms

Post‐treatment

Nine studies provided data on the severity of PTSD symptoms post‐treatment (Borghini 2014; Brom 1993; Gamble 2005; Jones 2010; Marchand 2006; Mouthaan 2013; Rothbaum 2012; Ryding 2004; Zatzick 2001). Meta‐analysis showed no evidence of a difference between multiple session early psychological interventions and treatment as usual (SMD –0.09, 95% CI –0.29 to 0.12; studies = 9; participants = 1326; Analysis 1.5). There was a high degree of heterogeneity in this result (I² = 67%).

When analysed by type of intervention, evidence from one study of 300 participants indicated that self‐guided Internet‐based CBT may be more effective than treatment as usual (SMD –0.38, 95% CI –0.61 to –0.15). Another study of 330 participants showed that intensive care diaries may be more effective than delayed access to diaries in reducing severity of PTSD symptoms postintervention (SMD –0.22, 95% CI –0.44 to –0.01). There was very high imprecision (wide confidence intervals) in estimating differences between treatment as usual and brief individual trauma processing therapy (SMD 0.04, 95% CI –0.34 to 0.425; I² = 76%; studies = 4; participants = 46), group counselling (SMD –0.09, 95% CI –0.41 to 0.24; studies = 1; participants = 147), collaborative care (SMD –0.50, 95% CI –1.24 to 0.25; studies = 1; participants = 29), three‐step early intervention (SMD 0.33, 95% CI –0.20 to 0.86; studies = 1; participants = 55).

It is evident that the heterogeneity in the group of participants who received brief individual trauma processing therapy contributed to the overall heterogeneity observed. It was not possible to investigate heterogeneity by number of sessions of the intervention, time between trauma exposure and intervention or type of traumatic event. However, it was possible to undertake a sensitivity analysis to look into gender of participants. Of the four studies on brief individual trauma processing therapy, one was done in women only (Gamble 2005). However, removing this study from the meta‐analysis had little effect on the heterogeneity within this group (I² = 82%). In the subgroup analysis, there was no evidence (Χ²=0.89, P=0.35) of difference between studies of brief individual trauma processing therapy targeting women only (SMD –0.19, 95% CI –0.58 to 0.20; studies = 1; participants = 102) and studies where gender was mixed (SMD 0.12, 95% CI –0.39 to 0.62; studies = 3; participants = 363). But the small number of studies limits the ability to identify differences between subgroups.

We planned to perform a sensitivity analysis excluding studies with unclear allocation concealment, high levels of post‐randomisation losses (greater than 40%) and unblinded outcome assessment or blinding of outcome assessment uncertain. However, this was not possible as three studies were at unclear risk of selection bias (Brom 1993; Gamble 2005; Marchand 2006), two studies were at high risk of attrition bias (Brom 1993; Rothbaum 2012), and two studies failed to blind or failed to report the blinding of outcome assessors (Brom 1993; Gamble 2005).

One study measured severity of PTSD symptoms using the PCL‐17 (Biggs 2016). Data were not in a usable format for meta‐analysis. Authors reported that the severity of PTSD symptoms did not differ significantly between the intervention and control group at one or two months' post‐treatment.

Three to six months' follow‐up

Fifteen studies provided data on the severity of PTSD symptoms at three to six months' follow‐up (Als 2015; Borghini 2014; Brom 1993; Brunet 2013; Curtis 2016; Gamble 2005; Holmes 2007; Irvine 2011; Jensen 2016; Jones 2010; Kazak 2005; Marchand 2006; Mouthaan 2013; Rothbaum 2012; Zatzick 2001). There was no significant difference in severity of PTSD symptoms between multiple session early psychological interventions and treatment as usual (SMD –0.10, 95% CI –0.22 to 0.02; I² = 34%; studies = 15; participants = 1921; low‐certainty evidence; Analysis 1.6).

When analysed by type of intervention, evidence from one study (300 participants) indicated that self‐guided Internet‐based CBT may be more effective than treatment as usual (SMD –0.27, 95% CI –0.50 to –0.04). Two studies on a total of 103 participants showed that brief dyadic therapy may be more effective in reducing severity of PTSD symptoms three to six months' post‐treatment (SMD –0.41, 95% CI –0.81 to –0.02). None of the other interventions (brief individual trauma processing therapy, collaborative care, brief IPT, intensive care diaries, three‐step early intervention, telephone‐based CBT, supported psychoeducation, communication facilitation in an ICU setting and nurse‐led ICU recovery programme), showed any evidence of effectiveness over treatment as usual in the severity of PTSD symptoms three to six months' postintervention.

One study measured severity of PTSD at six months but could not be entered in the meta‐analysis as authors did not report SDs (Andre 1997). The mean IES in the group receiving CBT decreased from 21.7 to 17.2, while the mean IES in the control group decreased from 15.6 to 12.0. However, data were only available for 39/65 participants in the intervention group and 45/67 in the control group.

Seven to 12 months' follow‐up

Four studies provided data on the severity of PTSD symptoms at seven to 12 months' follow‐up (Borghini 2014; Irvine 2011; Jensen 2016; Mouthaan 2013). There was no evidence of difference in severity of PTSD symptoms between multiple session early psychological interventions and treatment as usual (SMD –0.09, 95% CI –0.32 to 0.14; I² = 57%; studies = 4; participants = 765; Analysis 1.7).

It was not possible to investigate heterogeneity by number of sessions of the intervention, time between trauma exposure and intervention, or type of traumatic event. One study was conducted in women only, but excluding this from the meta‐analysis had little effect on the heterogeneity (I² = 70%) (Borghini 2014). We planned to perform a sensitivity analysis excluding studies at high risk of bias. However, this was not possible as three of the four studies which measured this outcome at seven to 12 months were at unclear risk of selection bias (Irvine 2011), unclear risk of detection bias (Borghini 2014; Jensen 2016), and high risk of attrition bias (Borghini 2014; Jensen 2016).

When analysed by type of intervention, evidence from one study (185 participants) indicated that telephone‐based CBT may be more effective than treatment as usual (SMD –0.38, 95% CI –0.67 to –0.09). For all other comparisons, confidence intervals were wide reflecting uncertainty in differences between treatment as usual and self‐guided Internet‐based CBT (SMD 0.00, 95% CI –0.23 to 0.23; studies = 1; participants = 300), three‐step early intervention (SMD –0.18, 95% CI –0.71 to 0.35; studies = 1; participants = 55), or nurse‐led intensive care recovery programme (SMD 0.12, 95% CI –0.14 to 0.38; studies = 1; participants = 225).

The study by Wang 2015 measured severity of PTSD symptoms at 12 months' follow‐up. Authors did not report SDs and, therefore, it could not be used in a meta‐analysis. There were no significant differences between group in terms of PTSD severity as measured by the CAPS score (P = 0.74) or the IES‐R score (P = 0.68).

2. Severity of depressive symptoms

Post‐treatment

Five studies reported data on severity of depressive symptoms post‐treatment (Holmes 2007; Mouthaan 2013; Rothbaum 2012; Ryding 2004; Zatzick 2001). Meta‐analysis indicated a lack of evidence of difference between multiple session early psychological interventions and treatment as usual at postintervention (SMD –0.19, 95% CI –0.40 to 0.01; I² = 35%; studies = 5; participants = 671; Analysis 1.8).

When analysed by type of intervention, evidence from one study (137 participants) indicated that brief individual trauma processing therapy may be more effective than treatment as usual (SMD –0.46, 95% CI –0.80 to –0.12). There was a lack of evidence of a difference between treatment as usual and self‐guided Internet‐based CBT (SMD –0.17, 95% CI –0.39 to 0.06; studies = 1; participants = 300), group therapy (SMD –0.22, 95% CI –0.55 to 0.10; studies = 1; participants = 147). There were very wide confidence intervals when comparing treatment as usual with collaborative care (SMD –0.26, 95% CI –0.99 to 0.48; studies = 1; participants = 29), or brief IPT (SMD 0.32, 95% CI –0.20 to 0.84; studies = 1; participants = 58).

One study measured severity of depression using the PHQ‐9 (Biggs 2016). Data were not in a usable format for meta‐analysis. Authors reported that the severity of PTSD symptoms did not differ significantly between the intervention and control group at one or two months' post‐treatment.

Three to six months' follow‐up

Seven studies reported data on severity of depressive symptoms at three to six months' follow‐up (Als 2015; Curtis 2016; Holmes 2007; Irvine 2011; Jensen 2016; Mouthaan 2013; Zatzick 2001). Meta‐analysis indicated no difference between multiple session early psychological interventions and treatment as usual (SMD –0.04, 95% CI –0.19 to 0.10; I² = 6%; studies = 7; participants = 1009; low‐certainty evidence; Analysis 1.9).

When analysed by type of intervention, there was no statistically significant difference between any specific intervention and treatment as usual.

One study measured depression at six months (Andre 1997). However, SDs were not reported and the study could not be entered in the meta‐analysis. Authors reported that the mean change in HAD score was 3.2 in the intervention group and 3.3 in the control group. There was a large loss to follow‐up in this study; data were only available for 39/65 participants in the intervention group and 45/67 in the control group.

Seven to 12 months' follow‐up

Three studies reported data on severity of depressive symptoms at seven to 12 months' follow‐up (Irvine 2011; Jensen 2016; Mouthaan 2013). Meta‐analysis indicated no evidence of difference between multiple session early psychological interventions and treatment as usual (SMD 0.01, 95% CI –0.14 to 0.15; I² = 0%; studies = 3; participants = 745; Analysis 1.10).

When analysed by type of intervention, there was no difference between any specific intervention and treatment as usual.

One study measured severity of depression at 12 months' follow‐up (Wang 2015). Authors did not report SDs and, therefore, it could not be used in a meta‐analysis. The mean change in depression according to HADS was 3.29 in the treatment and 3.15 in the control group (P = 0.64).

3. Severity of anxiety symptoms

Post‐treatment

Three studies provided data on the severity of anxiety symptoms post‐treatment (Holmes 2007; Kazak 2005; Mouthaan 2013). Meta‐analysis indicated no statistically significant difference between groups in the severity of anxiety symptoms postintervention (SMD –0.41, 95% CI –0.98 to 0.16; I² = 65%; studies = 3; participants = 358; Analysis 1.11).

It was not possible to investigate heterogeneity by number of sessions of the intervention, time between trauma exposure and intervention, type of traumatic event or gender of participants. We planned to perform a sensitivity analysis excluding studies at high risk of bias but this was not possible as two studies were at high risk of attrition bias (Holmes 2007; Kazak 2005), and two were at high risk of other bias (Kazak 2005; Mouthaan 2013).

When analysed by type of intervention, there was no statistically significant difference between treatment as usual and self‐guided Internet‐based therapy (SMD –0.03, 95% CI –0.25 to 0.20; I² = 0%; studies = 1; participants = 300). Although compared with treatment as usual there was evidence of potential benefit for brief dyadic therapy (SMD –0.76, 95% CI –1.54 to 0.02; studies = 1; participants = 29) or brief IPT (SMD –0.76, 95% CI –1.54 to 0.02; studies = 1; participants = 29) confidence intervals were too wide to rule out no difference.

Three to six months' follow‐up

Six studies provided data on the severity of anxiety symptoms at three to six months' follow‐up (Als 2015; Curtis 2016; Irvine 2011; Jensen 2016; Kazak 2005; Mouthaan 2013). Meta‐analysis indicated no difference between multiple session early psychological interventions and treatment as usual (SMD –0.05, 95% CI –0.19 to 0.10; I² = 2%; studies = 6; participants = 945; low‐certainty evidence; Analysis 1.12).

When analysed by type of intervention, there was no significant difference between any multiple session early psychological treatment and treatment as usual.

One study measured anxiety at six months (Andre 1997). However, SDs were not reported and the study could not be entered in the meta‐analysis. Authors reported that the mean change in HAD score was 6.2 in the intervention group and 6.8 in the control group. There was a large loss to follow‐up in this study; data were only available for 39/65 participants in the intervention group and 45/67 in the control group.

Seven to 12 months' follow‐up

Three studies provided data on the severity of anxiety symptoms at seven to 12 months' follow‐up (Irvine 2011; Jensen 2016; Mouthaan 2013). Meta‐analysis indicated no statistically significant difference between multiple session early psychological interventions and treatment as usual (SMD –0.04, 95% CI –0.27 to 0.18; I² = 58%; studies = 3; participants = 746; Analysis 1.13).

It was not possible to investigate heterogeneity by number of sessions of the intervention, time between trauma exposure and intervention, type of traumatic event or gender of participants. We planned to perform a sensitivity analysis excluding studies at high risk of bias. However, this was not possible as two of the three studies which measured this outcome at seven to 12 months, were at unclear risk of selection bias (Irvine 2011), unclear risk of detection bias (Jensen 2016), and high risk of attrition bias (Jensen 2016).

When analysed by type of intervention, evidence from one study of 185 participants indicated that telephone‐based CBT may be more effective than treatment as usual (SMD –0.30, 95% CI –0.59 to –0.01). It was unclear if self‐guided Internet‐based CBT (SMD 0.09, 95% CI –0.13 to 0.32; studies = 1; participants = 300), or nurse‐led intensive care diaries (SMD 0.04, 95% CI –0.21 to 0.28; studies = 1; participants = 261) were more or less effective than treatment as usual.

One study measured severity of anxiety at 12 months' follow‐up (Wang 2015). Authors did not report SDs and, therefore, it could not be used in a meta‐analysis. The mean change in anxiety according to HADS was 4.10 in the treatment group and 3.85 in the control group (P = 0.36).

4. Adverse effects

No studies provided data on adverse effects.

5. General functioning

One study measured quality of life using the WHOQOL‐BREF (Biggs 2016). Data were not in a usable format for meta‐analysis. Authors reported that the severity of PTSD symptoms did not differ significantly between the intervention and control groups at one, two, four, seven or 10 months' post‐treatment.

6. Use of health‐related resources

No studies provided data on use of health‐related resources.

Comparison 2: any intervention versus other psychological intervention

Six studies compared a psychological intervention against another active intervention (Cox 2018a; Gamble 2010; Gidron 2001; Gidron 2007; Lindwall 2014; Wijesinghe 2015). However, two of the studies provided no useable data and, therefore, could not be included in the meta‐analyses (Lindwall 2014; Wijesinghe 2015).

Primary outcome

1. PTSD diagnosis

One study measured PTSD diagnosis using the Post‐traumatic Stress Symptom Scale. As this is a self‐reported rather than clinician‐administered tool, this study was not included in the meta‐analysis (Wijesinghe 2015).

Post‐treatment

No study measured PTSD diagnosis post‐treatment.

Three to six months' follow‐up

No study measured PTSD diagnosis post‐treatment using a clinician‐administered tool.

Seven to 12 months' follow‐up

No study measured PTSD diagnosis at seven to 12 months' follow‐up.

2. Dropouts from treatment

Two studies provided data on number of dropouts for any reason,showing participants in early intervention groups were more likely to drop out than active controls (RR 1.61, 95% CI 1.11 to 2.34; I² = 0%; studies = 2; participants = 425; low‐certainty evidence; Analysis 2.1) (Cox 2018a; Gamble 2010). When analysed by type of intervention, there may be higher drop out for brief individual trauma processing therapy compared with parenting support (RR 1.78, 95% CI 1.12 to 2.84; studies = 1; participants = 262). It was uncertain if there was a difference in drop out between guided self‐help and physical education (RR 1.33, 95% CI 0.71 to 2.50; studies = 1; participants = 163).

Secondary outcomes

1. Severity of PTSD symptoms

Five studies provided data on severity of PTSD symptoms (Cox 2018a; Gamble 2010; Gidron 2001; Gidron 2007; Lindwall 2014), but only four could be entered in a meta‐analysis (Cox 2018a; Gamble 2010; Gidron 2001; Gidron 2007).

Post‐treatment

Two studies provided data on severity of PTSD symptoms post‐treatment (Cox 2018a; Gamble 2010). Meta‐analysis showed a lack of evidence for difference between treatments (SMD 0.13, 95% CI –0.06 to 0.33; I² = 0%; studies = 2; participants = 392; Analysis 2.2). When analysed by type of intervention, there was imprecision (wide confidence intervals) in estimating differences between brief individual trauma processing therapy and parenting support (SMD 0.14, 95% CI –0.13 to 0.41; studies = 1; participants = 217), or guided self‐help and physical education (SMD 0.13, 95% CI –0.17 to 0.42; studies = 1; participants = 175).

Three to six months' follow‐up

Four studies provided data on severity of PTSD symptoms at three to six months' follow‐up (Cox 2018a; Gamble 2010; Gidron 2001; Gidron 2007). There was a wide confidence interval indicating uncertainty on differences between treatments (SMD –0.02, 95% CI –0.31 to 0.26; I² = 43%; studies = 4; participants = 465; low‐certainty evidence; Analysis 2.3).

It was not possible to investigate heterogeneity by number of sessions of the intervention, time between trauma exposure and intervention, type of traumatic event or gender of participants. We planned to perform a sensitivity analysis excluding studies at high risk of bias. However, this was not possible as three of the four studies which measured this outcome at three to six months were at unclear risk of selection bias (Gamble 2010; Gidron 2001; Gidron 2007), unclear risk of detection bias (Gamble 2010), and high risk of attrition bias (Gamble 2010; Gidron 2001; Gidron 2007).

When analysed by type of intervention, confidence intervals were wide reflecting a lack of certainty on differences between brief individual trauma processing therapy and supportive listening (SMD –0.54, 95% CI –1.42 to 0.34; I² = 52%; studies = 2; participants = 51), brief individual trauma processing therapy and parenting support (SMD 0.06, 95% CI –0.19 to 0.31; studies = 1; participants = 239), or guided self‐help and physical education (SMD 0.13, 95% CI –0.16 to 0.43; studies = 1; participants = 175).

One study measured severity of PTSD symptoms in parents of children undergoing stem cell transplantation (Lindwall 2014). A child‐targeted intervention (massage and humour therapy) was compared with a child‐targeted plus a parent‐targeted intervention (massage, relaxation, imagery). Data could not be included in the meta‐analysis. Authors reported no significant differences between interventions (P = 0.45), but that PTSD did decrease significantly from baseline to six months for the two intervention groups as a whole (P < 0.001).

Seven to 12 months' follow‐up

One study provided data on severity of PTSD symptoms at seven to 12 months' follow‐up (Gamble 2010). There was no evidence of a significant difference between brief individual trauma processing therapy and parenting support (MD 1.27, 95% CI –0.60 to 3.14; studies = 1; participants = 200; Analysis 2.4),

2. Severity of depressive symptoms

Three studies measured severity of depressive symptoms (Cox 2018a; Gamble 2010; Lindwall 2014), but only two provided data that could be used in a meta‐analysis (Cox 2018a; Gamble 2010).

Post‐treatment

Two studies provided data on severity of depressive symptoms post‐treatment (Cox 2018a; Gamble 2010). There was no evidence of a significant difference between treatments (SMD 0.12, 95% CI –0.08 to 0.32; I² = 0%; studies = 2; participants = 392; Analysis 2.5). When analysed by type of intervention, there was a wide confidence interval when comparing brief individual trauma processing therapy and parenting support (SMD 0.06, 95% CI –0.21 to 0.33; studies = 1; participants = 217) suggesting a lack of certainty on group differences. Although the direction of effect favoured physical education over guided self help the difference wasn't statistically significant (SMD 0.19, 95% CI –0.11 to 0.49; studies = 1; participants = 175).

Three to six months' follow‐up

Two studies provided data on severity of depressive symptoms at three to six months' follow‐up (Cox 2018a; Gamble 2010). There was no evidence of a difference between treatments (SMD 0.04, 95% CI –0.16 to 0.23; I² = 0%; studies = 2; participants = 409; low‐certainty evidence; Analysis 2.6). When analysed by type of intervention, there was no evidence of a difference between brief individual trauma processing therapy and parenting support (SMD 0.09, 95% CI –0.17 to 0.34; studies = 1; participants = 234) or guided self‐help and physical education (SMD –0.04, 95% CI –0.33 to 0.26; studies = 1; participants = 175).

One study measured depression in parents of children undergoing stem cell transplantation using the CES‐D scale (Lindwall 2014). Data could not be entered into a meta‐analysis but authors reported no significant differences between groups a child‐targeted intervention (massage and humour therapy) with child‐targeted plus a parent‐targeted (massage, relaxation, imagery) intervention (P = 0.63).

Seven to 12 months' follow‐up

One study provided data on severity of depressive symptoms at seven to 12 months' follow‐up (Gamble 2010). There was no evidence of a difference between brief individual trauma processing therapy and parenting support (MD 0.79, 95% CI –0.66 to 2.24; studies = 1; participants = 198; Analysis 2.7).

3. Severity of anxiety symptoms

Post‐treatment

Two studies provided data on severity of anxiety symptoms post‐treatment (Cox 2018a; Gamble 2010). There was no evidence of a significant difference between treatments (SMD 0.08, 95% CI –0.12 to 0.28; I² = 0%; studies = 2; participants = 392; Analysis 2.8). When analysed by type of intervention, there was no evidence of a significant difference between brief individual trauma processing therapy and parenting support (SMD 0.10, 95% CI –0.17 to 0.37; studies = 1; participants = 217) or guided self‐help and physical education (SMD 0.05, 95% CI –0.24 to 0.35; studies = 1; participants = 175).

Three to six months' follow‐up

Two studies provided data on severity of anxiety symptoms at three to six months' follow‐up (Cox 2018a; Gamble 2010). There was no evidence of a difference between treatments (SMD 0.00, 95% CI –0.19 to 0.19; I² = 0%; studies = 2; participants = 414; low‐certainty evidence; Analysis 2.9). When analysed by type of intervention, there was no evidence of a difference between brief individual trauma processing therapy and parenting support (SMD 0.03, 95% CI –0.22 to 0.28; studies = 1; participants = 239) or guided self‐help and physical education (SMD –0.04, 95% CI –0.33 to 0.26; studies = 1; participants = 175).

Seven to 12 months' follow‐up

One study provided data on severity of anxiety symptoms at seven to 12 months' follow‐up (Gamble 2010). There was a very wide confidence interval when comparing brief individual trauma processing therapy with parenting support (MD –0.07, 95% CI –1.58 to 1.44; studies = 1; participants = 199; Analysis 2.10).

4. Adverse effects

No studies provided data on adverse effects. One study reported interactions between initial traumatic stress symptoms, psychiatric history, past psychiatric diagnosis and IPT intervention in predicting worse PTSD symptoms at six months (Holmes 2007).

5. General functioning

Post‐treatment

One study measured general functioning using the HRQoL (Gamble 2010). There was no difference between counselling aimed at promoting resilience and parenting support (MD –0.02, 95% CI –0.05 to 0.01; studies = 1; participants = 218; Analysis 2.11).

Three to six months' follow‐up

One study measured general functioning at three to six months' post‐treatment (Gamble 2010). There was no significant difference between counselling aimed at promoting resilience and parenting support (MD –0.03, 95% CI –0.06 to 0.00; studies = 1; participants = 239; low‐certainty evidence; Analysis 2.12).

Seven to 12 months' follow‐up

One study found no difference in general functioning at seven to 12 months' post‐treatment (MD 0.01, 95% CI –0.03 to 0.05; studies = 1; participants = 199; Analysis 2.13) (Gamble 2010).

6. Use of health‐related resources

No studies provided data on use of health‐related resources.

Publication bias

All of the studies identified for this review were published, apart from one (Gamble 2010). Only two comparisons were sufficiently large for us to be able to conduct funnel plots (Analysis 1.6; Analysis 1.4). Visual inspection of these plots suggested that there was no indication of asymmetry (Figure 4; Figure 5). We were unable to investigate the plots by intervention.

Figure 4

Funnel plot of comparison: 1 Any early psychological intervention versus waiting list/usual care, outcome: 1.5 Severity of PTSD symptoms: 3–6 months. TAU: treatment as usual.

Figure 5

Funnel plot of comparison: 1 Any early psychological intervention versus waiting list/usual care, outcome: 1.13 Dropouts for any reason. CBT: cognitive behavioural therapy; IPT: interpersonal therapy; TAU: treatment as usual.

Discusión

disponible en

Resumen de los resultados principales

Se identificaron 27 ECA (3963 participantes) de intervenciones psicológicas iniciales con sesiones múltiples que comenzaron dentro de los tres meses de un evento traumático, diseñados para prevenir los síntomas de estrés traumático. Veintiún estudios de 2721 participantes aportaron datos utilizables y se incluyeron en un metanálisis.

Las intervenciones psicológicas iniciales de sesiones múltiples pueden ser más efectivas que el tratamiento habitual para reducir el número de pacientes con diagnóstico de TEPT de tres a seis meses después de recibir la intervención. Sin embargo, no hubo diferencias significativas entre los dos grupos inmediatamente después del tratamiento o a los siete a 12 meses de seguimiento. La evidencia no fue lo suficientemente sólida como para sugerir que las intervenciones psicológicas iniciales pueden ser más efectivas que el tratamiento habitual para reducir la gravedad de los síntomas del TEPT, la depresión y la ansiedad en cualquier punto temporal. Las diferencias en los abandonos no fueron significativas. En cuanto a los tipos específicos de intervención, los diarios de cuidados intensivos pueden ser más efectivos que el tratamiento habitual para reducir el número de pacientes diagnosticados con TEPT según los datos de un estudio (Jones 2010), aunque no se encontraron diferencias en cuanto a la gravedad del TEPT; la intervención autoguiada por Internet puede ser más efectiva que el tratamiento habitual para reducir la gravedad del TEPT basado en los datos de un estudio (Mouthaan 2013); la terapia diádica breve puede ser más efectiva que el tratamiento habitual para reducir la gravedad del TEPT de acuerdo a los datos de dos estudios (Brunet 2013; Mouthaan 2013). No se encontró evidencia del efecto de ninguna otra intervención.

No hubo diferencias significativas entre las intervenciones psicológicas iniciales de sesiones múltiples y las intervenciones de control activo en cuanto al diagnóstico del TEPT, la reducción de la gravedad de la depresión y la ansiedad, o la mejoría de la funcionalidad general del receptor después de la intervención o a los tres a 12 meses de seguimiento. Sin embargo, los participantes que recibieron intervenciones de sesiones múltiples tuvieron más probabilidades de interrumpir la intervención de forma precoz.

Compleción y aplicabilidad general de las pruebas

Los estudios incluidos en esta revisión consideran directamente la pregunta principal de la revisión. Fue posible realizar metanálisis de ECA de intervenciones psicológicas de sesiones múltiples dirigidas a prevenir el TEPT en individuos que habían estado expuestos a un evento traumático pero que no habían sido identificados como personas que experimentaban dificultades psicológicas específicas. Sin embargo, no fue posible realizar el metanálisis para todos los resultados y el número limitado de estudios, los tamaños de la muestra pequeños y la heterogeneidad (ver más abajo) complican la interpretación. La pregunta de cómo funcionan las intervenciones en comparación con otras intervenciones psicológicas sólo se podría responder para las intervenciones de estructuras de memoria y no para otras. El número de estudios nuevos identificados en la búsqueda más reciente (ver tabla de Características de los estudios en espera de clasificación) sugiere que ésta es un área que cambia rápidamente, particularmente en términos de la intervención psicológica inicial en ámbitos médicos y que se requerirá una revisión actualizada adicional en un futuro cercano.

Debido a la prominencia de las intervenciones cognitivo‐conductuales en la base de evidencia para las terapias psicológicas, es sorprendente que sólo tres de los estudios identificados en esta revisión evaluaran una intervención de TCC (Andre 1997; Irvine 2011; Rothbaum 2012), aunque otros siete estudios incluyeron componentes de TCC en sus intervenciones (Brunet 2013; Cox 2018a; Kazak 2005; Marchand 2006; Mouthaan 2013; Wijesinghe 2015; Zatzick 2001). Andre 1997 informó una disminución significativa en los síntomas intrusivos y la ansiedad en su grupo de tratamiento. Desafortunadamente, los datos proporcionados en el artículo no permitieron su inclusión en el metanálisis. Las intervenciones evaluadas con mayor frecuencia fueron las terapias breves individuales de procesamiento del trauma que se basaron en varios modelos teóricos diferentes, pero que compartían componentes activos del tratamiento. La evidencia examinada no proporcionó ningún apoyo para este enfoque como intervención preventiva.

Los participantes en los estudios incluidos de la revisión estuvieron expuestos a eventos traumáticos individuales únicos, y no hubo estudios sobre los eventos traumáticos a gran escala como los desastres o las guerras, lo que limita la validez externa de los resultados a la amplia variedad de eventos traumáticos.

Desafortunadamente, aparte de los estudios en que los participantes presentaban enfermedades graves y un alto riesgo de mortalidad (Irvine 2011; Jensen 2016; Jones 2010), sólo un estudio consideró los efectos adversos (Holmes 2007), y no estaba claro si hubo efectos adversos en los otros estudios. La ausencia de evaluación de la tolerabilidad (una evaluación del grado en que los pacientes pueden soportar los efectos adversos no deseados de una intervención) es una deficiencia importante en los ECA identificados y que se ha observado previamente en los estudios del tratamiento psicológico del TEPT crónico (Bisson 2007).

Calidad de la evidencia

Heterogeneidad

Hubo pruebas de heterogeneidad clínica y estadística en los estudios incluidos. Aunque todos los ensayos intentaron prevenir los síntomas del TEPT, la naturaleza de las intervenciones incluidas en los metanálisis fue muy diversa. Las intervenciones incluidas en el metanálisis primario fueron dos sesiones de TCC diádica breve (Brunet 2013), dos sesiones de asesoramiento (una personal y una por teléfono) (Gamble 2005), dos sesiones de informe psicológico adaptado del estrés del incidente crítico (marzo y 2006), la posibilidad de compartir un diario de cuidados intensivos (Jones 2010), una intervención breve autoguiada por Internet (Mouthaan 2013) y tres sesiones de exposición prolongada modificada (Rothbaum 2012). Fue muy difícil comparar dichos ensayos y pareció haber algunas diferencias en los resultados, por ejemplo, Jones 2010 pareció ser más efectivo que Marchand 2006.

También hubo diferencias en las poblaciones clínicas, que incluían víctimas de accidentes automovilísticos, víctimas de robos a mano armada o agresiones, asistentes de funerarias militares, personas de las UCI, mujeres que tuvieron cesáreas de emergencia o bebés prematuros, padres de niños que se encontraban en la UCI o que habían sido diagnosticados con cáncer de forma reciente. Desafortunadamente, el número limitado de ensayos impidió la realización de análisis de sensibilidad para explorar de forma adicional estos temas. La heterogeneidad estadística fue evidente en varios análisis; el valor de I² demuestra las inconsistencias en los resultados de algunos ensayos que se agruparon. Cuando hubo heterogeneidad estadística, se utilizó un modelo de efectos aleatorios en lugar de un modelo de efectos fijos para calcular IC más conservadores. Se establece la conclusión de que todos los ensayos trataron esencialmente de medir el mismo resultado y que fue valioso resumir los resultados combinados, aunque la variación dio lugar a que se deba tener precaución al interpretar los resultados (Fletcher 2007).

Certeza metodológica

Se utilizaron los cinco criterios GRADE (limitaciones del estudio, consistencia del efecto, imprecisión, falta de direccionalidad y sesgo de publicación) para evaluar la certeza del grupo de evidencia para cada resultado, y para extraer conclusiones sobre la certeza de la evidencia en el texto de la revisión. Una de las principales consideraciones para disminuir las evaluaciones con criterios GRADE fue el riesgo de sesgo. Las inquietudes sobre la certeza de la evidencia también limitan el grado en que pueden generalizarse las conclusiones. Para obtener detalles sobre los juicios del riesgo de sesgo para cada estudio, ver la tabla de Características de los estudios incluidos y la representación gráfica del riesgo de sesgo presentada en la Figura 2 y la Figura 3.

Hubo varios aspectos problemáticos en varios estudios, incluido el proceso de asignación al azar, el informe incompleto de los abandonos y la falta de un tratamiento específico repetible y estandarizado. Del mismo modo que todos los ensayos de tratamientos psicológicos hay problemas con los grupos control. Lo anterior es particularmente importante en las investigaciones de intervención donde es de esperar una reducción de los síntomas con la duración del ensayo, debido al curso natural de las reacciones al estrés traumático. El desarrollo de un "placebo de tratamiento psicológico" es muy difícil, si no imposible, como lo es el cegamiento de los participantes y los terapeutas. Algunos grupos de lista de espera o atención habitual pueden haber recibido alguna forma de intervención mediante el contacto para monitorizar los síntomas; sin embargo lo anterior no se evaluó de manera adecuada y no es posible determinar qué repercusión tuvo en los resultados, si hubo alguna. Los cuatro estudios que tuvieron un grupo de control activo no mostraron diferencias entre las intervenciones psicológicas iniciales de sesiones múltiples (Cox 2018a; Gamble 2010; Gidron 2001; Gidron 2007).

Los tamaños de la muestra pequeños de la mayoría de los estudios constituyen también una limitación importante. Sin embargo, los grupos de intervención y control en la mayoría de los estudios parecieron bien pareados al inicio, lo que reduce el riesgo de los resultados medios no ajustados influenciados por las diferencias iniciales. Se intentó realizar análisis de subgrupos que investigaran la heterogeneidad en cuanto al tipo de trauma y el número de sesiones de la intervención, aunque no hubo suficientes estudios para realizarlos.

Sesgos potenciales en el proceso de revisión

Esta revisión cumplió estrictamente con las guías Cochrane (Higgins 2011). Dos autores de revisión examinaron de forma independiente los resúmenes identificados mediante la búsqueda bibliográfica; leyeron todos los estudios potencialmente pertinentes; evaluaron cada estudio de acuerdo a los criterios de inclusión; extrajeron los datos de los informes escritos y calificaron cada estudio según el riesgo de sesgo. Cualquier desacuerdo se debatió con un tercer autor de la revisión, y se lograron decisiones unánimes para la inclusión y la clasificación. Se siguieron cuidadosamente las guías establecidas por Cochrane sobre métodos estadísticos y se utilizaron los criterios GRADE para evaluar la certeza de la evidencia (Higgins 2011). El hecho de respetar estos procedimientos redujo al mínimo el potencial de sesgo, aunque aún se observaron cuestiones inevitables.

Se habían publicado todos los estudios incluidos en la revisión excepto Gamble 2010, lo que dio lugar a la posibilidad de sesgo de publicación. No fue posible realizar una investigación sobre el posible sesgo de publicación para el resultado primario, aunque se pudieron generar gráficos en embudo para dos comparaciones y no se encontró evidencia que sugiriera la presencia de sesgo de publicación.

Se efectuaron búsquedas sistemáticas en numerosas bases de datos en línea para obtener estudios potencialmente relevantes, y se escrutaron las listas de referencias de los estudios incluidos. También se estableció contacto con los expertos en el área y se les solicitó ayuda para identificar los estudios omitidos o el trabajo en curso. No obstante, no es posible eliminar completamente la posibilidad de haber pasado por alto algún ECA.

Hubo una considerable heterogeneidad estadística en cuatro de las comparaciones agrupadas. En las circunstancias en las que se creyó que la heterogeneidad era potencialmente problemática, se utilizó un modelo de efectos aleatorios. La heterogeneidad también fue un factor que se tuvo en cuenta al disminuir la certeza de la evidencia con los criterios GRADE.

Acuerdos y desacuerdos con otros estudios o revisiones

Hasta lo que se sabe, ésta es la única revisión sistemática específica de las intervenciones de sesiones múltiples para prevenir el TEPT. Los resultados son congruentes con los hallazgos de la versión anterior de esta revisión (Roberts 2009). Los hallazgos también son congruentes con otras revisiones sistemáticas que han incluido estudios en esta área (NICE 2018), y también con las guías prevalecientes sobre cómo responder mejor después de un evento traumático (ACPMH 2007; NICE 2018).

Figure 1

PRISMA flow diagram.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 4

Funnel plot of comparison: 1 Any early psychological intervention versus waiting list/usual care, outcome: 1.5 Severity of PTSD symptoms: 3–6 months. TAU: treatment as usual.

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Figure 5

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Analysis 1.1

Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 1 PTSD diagnosis post‐treatment.

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Analysis 1.2

Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 2 PTSD diagnosis 3–6 months.

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Analysis 1.3

Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 3 PTSD diagnosis 7–12 months.

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Analysis 1.4

Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 4 Dropouts from treatment.

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Analysis 1.5

Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 5 Severity of PTSD symptoms post‐treatment.

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Analysis 1.6

Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 6 Severity of PTSD symptoms: 3–6 months.

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Analysis 1.7

Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 7 Severity of PTSD symptoms: 7–12 months.

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Analysis 1.8

Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 8 Severity of depressive symptoms post‐treatment.

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Analysis 1.9

Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 9 Severity of depressive symptoms at 3–6 months.

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Analysis 1.10

Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 10 Severity of depressive symptoms at 7–12 months.

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Analysis 1.11

Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 11 Severity of anxiety symptoms post‐treatment.

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Analysis 1.12

Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 12 Severity of anxiety symptoms at 3–6 months.

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Analysis 1.13

Comparison 1 Any early psychological intervention versus waiting list/usual care, Outcome 13 Severity of anxiety symptoms at 7–12 months.

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Analysis 2.1

Comparison 2 Any early psychological intervention versus active control condition, Outcome 1 Dropouts from treatment.

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Analysis 2.2

Comparison 2 Any early psychological intervention versus active control condition, Outcome 2 Severity of PTSD symptoms post‐treatment.

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Analysis 2.3

Comparison 2 Any early psychological intervention versus active control condition, Outcome 3 Severity of PTSD symptoms at 3–6 months.

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Analysis 2.4

Comparison 2 Any early psychological intervention versus active control condition, Outcome 4 Severity of PTSD symptoms at 7–12 months.

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Analysis 2.5

Comparison 2 Any early psychological intervention versus active control condition, Outcome 5 Severity of depression symptoms post‐treatment.

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Analysis 2.6

Comparison 2 Any early psychological intervention versus active control condition, Outcome 6 Severity of depressive symptoms at 3–6 months.

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Analysis 2.7

Comparison 2 Any early psychological intervention versus active control condition, Outcome 7 Severity of depressive symptoms at 7–12 months.

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Analysis 2.8

Comparison 2 Any early psychological intervention versus active control condition, Outcome 8 Severity of anxiety symptoms post‐treatment.

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Analysis 2.9

Comparison 2 Any early psychological intervention versus active control condition, Outcome 9 Severity of anxiety symptoms at 3–6 months.

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Analysis 2.10

Comparison 2 Any early psychological intervention versus active control condition, Outcome 10 Severity of anxiety symptoms at 7–12 months.

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Analysis 2.11

Comparison 2 Any early psychological intervention versus active control condition, Outcome 11 General functioning post‐treatment.

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Analysis 2.12

Comparison 2 Any early psychological intervention versus active control condition, Outcome 12 General functioning at 3–6 months.

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Analysis 2.13

Comparison 2 Any early psychological intervention versus active control condition, Outcome 13 General functioning at 7–12 months.

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Summary of findings for the main comparison. Any early psychological intervention compared to waiting list/usual care for the prevention of post‐traumatic stress disorder

Any early psychological intervention compared to waiting list/usual care for the prevention of post‐traumatic stress disorder
Patient or population: various Setting: various Intervention: any early psychological intervention Comparison: waiting list/usual care
Outcomes	№ of participants (studies)	Certainty of the evidence (GRADE)	Relative effect (95% CI)	*Anticipated absolute effects (95% CI)**
				Risk with waiting list/usual care	Risk difference with any early psychological intervention
PTSD diagnosis: post‐treatment	556 (5 RCTs)	⊕⊝⊝⊝ Very low^a,b	RR 1.06 (0.85 to 1.32)	Study population
				283 per 1000	17 more per 1000 (42 fewer to 91 more)
PTSD diagnosis: 3–6 months	758 (5 RCTs)	⊕⊕⊝⊝ Low^c,d	RR 0.62 (0.41 to 0.93)	Study population
				215 per 1000	82 fewer per 1000 (127 fewer to 15 fewer)
PTSD diagnosis: 7–12 months	132 (1 RCT)	⊕⊝⊝⊝ Very low^e,f	RR 0.94 (0.20 to 4.49)	Study population
				47 per 1000	3 fewer per 1000 (38 fewer to 164 more)
Dropouts from treatment	1154 (11 RCTs)	⊕⊕⊝⊝ Low^d,k	RR 1.34 (0.91 to 1.95)	Study population
				125 per 1000	43 more per 1000 (11 fewer to 119 more)
Severity of PTSD symptoms: 3–6 months	1921 (15 RCTs)	⊕⊕⊝⊝ Low^g,h	—	The mean severity of PTSD symptoms: 3–6 months was 0	SMD 0.1 lower (0.22 lower to 0.02 higher)
Severity of depressive symptoms: 3–6 months	1009 (7 RCTs)	⊕⊕⊝⊝ Low^g,i	—	The mean severity of depressive symptoms at 3–6 months was 0	SMD 0.04 lower (0.19 lower to 0.1 higher)
Severity of anxiety symptoms: 3–6 months	945 (6 RCTs)	⊕⊕⊝⊝ Low^g,j	—	The mean severity of anxiety symptoms at 3–6 months was 0	SMD 0.05 lower (0.19 lower to 0.10 higher)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; PTSD: post‐traumatic stress disorder; RCT: randomised controlled trial; RR: risk ratio; SMD: standardised mean difference.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aThree of the five studies were at high risk of bias (Brunet 2013; Mouthaan 2013; Rothbaum 2012). ^bDowngraded two levels for imprecision as the total number of events was fewer than 300 and 95% CI included both little or no effect. ^cThree of the five studies were at high risk of bias (Jones 2010; Mouthaan 2013; Rothbaum 2012). ^dDowngraded one level for imprecision as the total number of events was fewer than 300. ^eThe study was at high risk of bias (Mouthaan 2013). ^fDowngraded two levels as the total number of events was fewer than 300 and 95% CI included both little or no effect. ^gDowngraded one level for imprecision as the 95% CI includes both little or no effect. ^hTwelve of the 15 studies were at high risk of bias (Als 2015; Borghini 2014; Brom 1993; Brunet 2013; Curtis 2016; Holmes 2007; Jensen 2016; Jones 2010; Kazak 2005; Mouthaan 2013; Rothbaum 2012; Zatzick 2001). ⁱSix of the seven studies were at high risk of bias (Als 2015; Curtis 2016; Holmes 2007; Jensen 2016; Mouthaan 2013; Zatzick 2001). ^jFive of the six studies were at high risk of bias (Als 2015; Curtis 2016; Jensen 2016; Kazak 2005; Mouthaan 2013). ^kEight of the 11 studies were at high risk of bias (Brom 1993; Brunet 2013; Holmes 2007; Kazak 2005; Rothbaum 2012; Ryding 1998; Ryding 2004; Zatzick 2001).

Summary of findings for the main comparison. Any early psychological intervention compared to waiting list/usual care for the prevention of post‐traumatic stress disorder

Ir a la tabla de la revisión

Summary of findings 2. Any early psychological intervention compared to active control condition for the prevention of post‐traumatic stress disorder

Any early psychological intervention compared to active control condition for the prevention of post‐traumatic stress disorder
Patient or population: various Setting: various Intervention: any early psychological intervention Comparison: active control condition
Outcomes	№ of participants (studies)	Certainty of the evidence (GRADE)	Relative effect (95% CI)	*Anticipated absolute effects (95% CI)**
				Risk with active control condition	Risk difference with any early psychological intervention
Dropouts from treatment	425 (2 RCTs)	⊕⊕⊝⊝ Low^e,f	RR 1.61 (1.11 to 2.34)	Study population
				168 per 1000	103 more per 1000 (19 more to 225 more)
Severity of PTSD symptoms: 3–6 months	465 (4 RCTs)	⊕⊕⊝⊝ Low^c,d	—	The mean severity of PTSD symptoms at 3–6 months was 0	SMD 0.02 lower (0.31 lower to 0.26 higher)
Severity of depressive symptoms: 3–6 months	409 (2 RCTs)	⊕⊕⊝⊝ Low^d,e	—	The mean severity of depressive symptoms at 3–6 months was 0	SMD 0.04 higher (0.16 lower to 0.23 higher)
Severity of anxiety symptoms: 3–6 months	414 (2 RCTs)	⊕⊕⊝⊝ Low^d,e	—	The mean severity of anxiety symptoms at 3–6 months was 0	SMD 0 (0.19 lower to 0.19 higher)
General functioning: 3–6 months	239 (1 RCT)	⊕⊕⊝⊝ Low^g,h	—	The mean general functioning at 3–6 months was 0	MD 0.03 lower (0.06 lower to 0)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; MD: mean difference; PTSD: post‐traumatic stress disorder; RCT: randomised controlled trial; RR: risk ratio; SMD: standardised mean difference.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aStudy was at high risk of bias (Gidron 2001). ^bDowngraded two levels for imprecision as total number of events was fewer than 300 and 95% CI included both little or no effect. ^cAll four studies were at high risk or bias (Cox 2018a; Gamble 2010; Gidron 2001; Gidron 2007). ^dDowngraded one level for imprecision as 95% CI included both little or no effect. ^eBoth studies were at high risk of bias (Cox 2018a; Gamble 2010). ^fDowngraded one level for imprecision as total number of events was fewer than 300. ^gStudy was at high risk of bias (Gamble 2010). ^hDowngraded one level for imprecision as total number of participants was fewer than 400.

Summary of findings 2. Any early psychological intervention compared to active control condition for the prevention of post‐traumatic stress disorder

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Comparison 1. Any early psychological intervention versus waiting list/usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis post‐treatment Show forest plot	5	556	Risk Ratio (M‐H, Random, 95% CI)	1.06 [0.85, 1.32]

1.1 Brief individual trauma processing therapy vs treatment as usual (TAU)	3	262	Risk Ratio (M‐H, Random, 95% CI)	1.10 [0.87, 1.40]
1.2 Self‐guided Internet‐based intervention vs TAU	1	228	Risk Ratio (M‐H, Random, 95% CI)	0.91 [0.40, 2.06]
1.3 Brief dyadic cognitive‐behavioural intervention vs TAU	1	66	Risk Ratio (M‐H, Random, 95% CI)	0.59 [0.21, 1.61]
2 PTSD diagnosis 3–6 months Show forest plot	5	758	Risk Ratio (M‐H, Random, 95% CI)	0.62 [0.41, 0.93]

2.1 Brief individual trauma processing therapy vs TAU	3	251	Risk Ratio (M‐H, Random, 95% CI)	0.73 [0.44, 1.22]
2.2 Self‐guided Internet‐based intervention vs TAU	1	185	Risk Ratio (M‐H, Random, 95% CI)	0.50 [0.18, 1.45]
2.3 Intensive care diaries vs delayed intensive care diaries	1	322	Risk Ratio (M‐H, Random, 95% CI)	0.38 [0.17, 0.82]
3 PTSD diagnosis 7–12 months Show forest plot	1	132	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.20, 4.49]

3.1 Self‐guided Internet‐based intervention vs TAU	1	132	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.20, 4.49]
4 Dropouts from treatment Show forest plot	11	1154	Risk Ratio (M‐H, Random, 95% CI)	1.34 [0.91, 1.95]

4.1 Brief individual trauma processing therapy vs TAU	5	571	Risk Ratio (M‐H, Random, 95% CI)	1.06 [0.67, 1.68]
4.2 Brief dyadic therapy vs TAU	2	112	Risk Ratio (M‐H, Random, 95% CI)	2.09 [0.76, 5.75]
4.3 Group therapy vs TAU	1	162	Risk Ratio (M‐H, Random, 95% CI)	0.72 [0.27, 1.89]
4.4 Collaborative care vs TAU	1	34	Risk Ratio (M‐H, Random, 95% CI)	0.75 [0.14, 3.94]
4.5 Brief IPT vs TAU	1	90	Risk Ratio (M‐H, Random, 95% CI)	3.06 [1.39, 6.75]
4.6 Telephone‐based CBT vs TAU	1	185	Risk Ratio (M‐H, Random, 95% CI)	2.42 [0.79, 7.44]
5 Severity of PTSD symptoms post‐treatment Show forest plot	9	1326	Std. Mean Difference (IV, Random, 95% CI)	‐0.09 [‐0.29, 0.12]

5.1 Brief individual trauma processing therapy vs TAU	4	465	Std. Mean Difference (IV, Random, 95% CI)	0.04 [‐0.34, 0.42]
5.2 Self‐guided Internet‐based intervention vs TAU	1	300	Std. Mean Difference (IV, Random, 95% CI)	‐0.38 [‐0.61, ‐0.15]
5.3 Group counselling vs TAU	1	147	Std. Mean Difference (IV, Random, 95% CI)	‐0.09 [‐0.41, 0.24]
5.4 Collaborative care vs TAU	1	29	Std. Mean Difference (IV, Random, 95% CI)	‐0.50 [‐1.24, 0.25]
5.5 Intensive care diaries vs delayed access to intensive care diaries	1	330	Std. Mean Difference (IV, Random, 95% CI)	‐0.22 [‐0.44, ‐0.01]
5.6 Three‐step early intervention vs TAU	1	55	Std. Mean Difference (IV, Random, 95% CI)	0.33 [‐0.20, 0.86]
6 Severity of PTSD symptoms: 3–6 months Show forest plot	15	1921	Std. Mean Difference (IV, Random, 95% CI)	‐0.10 [‐0.22, 0.02]

6.1 Brief individual trauma processing therapy vs TAU	4	466	Std. Mean Difference (IV, Random, 95% CI)	‐0.05 [‐0.41, 0.30]
6.2 Self‐guided Internet‐based intervention vs TAU	1	300	Std. Mean Difference (IV, Random, 95% CI)	‐0.27 [‐0.50, ‐0.04]
6.3 Brief dyadic therapy vs TAU	2	103	Std. Mean Difference (IV, Random, 95% CI)	‐0.41 [‐0.81, ‐0.02]
6.4 Collaborative care vs TAU	1	26	Std. Mean Difference (IV, Random, 95% CI)	0.41 [‐0.37, 1.19]
6.5 Brief interpersonal therapy (IPT) vs TAU	1	58	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.42, 0.61]
6.6 Intensive care diaries vs delayed access to intensive care diaries	1	322	Std. Mean Difference (IV, Random, 95% CI)	0.0 [‐0.22, 0.22]
6.7 Three‐step early intervention vs TAU	1	55	Std. Mean Difference (IV, Random, 95% CI)	‐0.08 [‐0.61, 0.45]
6.8 Telephone‐based cognitive behavioural therapy (CBT) vs TAU	1	185	Std. Mean Difference (IV, Random, 95% CI)	‐0.20 [‐0.49, 0.09]
6.9 Supported psychoeducation vs TAU	1	23	Std. Mean Difference (IV, Random, 95% CI)	‐0.65 [‐1.61, 0.30]
6.10 Communication facilitator in an intensive care setting vs usual care	1	168	Std. Mean Difference (IV, Random, 95% CI)	0.02 [‐0.29, 0.32]
6.11 Nurse‐led intensive care recovery programme vs TAU	1	215	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.29, 0.25]
7 Severity of PTSD symptoms: 7–12 months Show forest plot	4	765	Std. Mean Difference (IV, Random, 95% CI)	‐0.09 [‐0.32, 0.14]

7.1 Self‐guided Internet‐based intervention vs wait list/TAU	1	300	Std. Mean Difference (IV, Random, 95% CI)	0.0 [‐0.23, 0.23]
7.2 Three‐step early intervention vs TAU	1	55	Std. Mean Difference (IV, Random, 95% CI)	‐0.18 [‐0.71, 0.35]
7.3 Telephone‐based CBT	1	185	Std. Mean Difference (IV, Random, 95% CI)	‐0.38 [‐0.67, ‐0.09]
7.4 Nurse‐led intensive care recovery programme vs TAU	1	225	Std. Mean Difference (IV, Random, 95% CI)	0.12 [‐0.14, 0.38]
8 Severity of depressive symptoms post‐treatment Show forest plot	5	671	Std. Mean Difference (IV, Random, 95% CI)	‐0.19 [‐0.40, 0.01]

8.1 Brief individual trauma processing therapy vs TAU	1	137	Std. Mean Difference (IV, Random, 95% CI)	‐0.46 [‐0.80, ‐0.12]
8.2 Self‐guided Internet‐based intervention vs TAU	1	300	Std. Mean Difference (IV, Random, 95% CI)	‐0.17 [‐0.39, 0.06]
8.3 Collaborative care vs TAU	1	29	Std. Mean Difference (IV, Random, 95% CI)	‐0.26 [‐0.99, 0.48]
8.4 Group therapy vs TAU	1	147	Std. Mean Difference (IV, Random, 95% CI)	‐0.22 [‐0.55, 0.10]
8.5 Brief IPT vs TAU	1	58	Std. Mean Difference (IV, Random, 95% CI)	0.32 [‐0.20, 0.84]
9 Severity of depressive symptoms at 3–6 months Show forest plot	7	1009	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.19, 0.10]

9.1 Brief IPT vs TAU	1	58	Std. Mean Difference (IV, Random, 95% CI)	0.0 [‐0.52, 0.52]
9.2 Self‐guided Internet‐based intervention vs TAU	1	300	Std. Mean Difference (IV, Random, 95% CI)	‐0.12 [‐0.35, 0.10]
9.3 Collaborative care vs TAU	1	26	Std. Mean Difference (IV, Random, 95% CI)	0.86 [0.05, 1.68]
9.4 Supported psychoeducational intervention vs TAU	1	23	Std. Mean Difference (IV, Random, 95% CI)	‐0.07 [1.00, 0.87]
9.5 Telephone‐based CBT	1	185	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
9.6 Communication facilitator in an intensive care setting vs TAU	1	171	Std. Mean Difference (IV, Random, 95% CI)	‐0.07 [‐0.37, 0.23]
9.7 Nurse‐led intensive care recovery programme vs TAU	1	246	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.29, 0.21]
10 Severity of depressive symptoms at 7–12 months Show forest plot	3	745	Std. Mean Difference (IV, Random, 95% CI)	0.01 [‐0.14, 0.15]

10.1 Self‐guided Internet‐based intervention vs TAU	1	300	Std. Mean Difference (IV, Random, 95% CI)	0.06 [‐0.17, 0.28]
10.2 Telephone‐based CBT	1	185	Std. Mean Difference (IV, Random, 95% CI)	‐0.16 [‐0.45, 0.13]
10.3 Nurse‐led intensive care recovery programme vs TAU	1	260	Std. Mean Difference (IV, Random, 95% CI)	0.06 [‐0.18, 0.30]
11 Severity of anxiety symptoms post‐treatment Show forest plot	3	358	Std. Mean Difference (IV, Random, 95% CI)	‐0.41 [‐0.98, 0.16]

11.1 Self‐guided Internet‐based intervention vs TAU	1	300	Std. Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.25, 0.20]
11.2 Brief dyadic therapy vs TAU	1	29	Std. Mean Difference (IV, Random, 95% CI)	‐0.76 [‐1.54, 0.02]
11.3 Brief IPT vs TAU	1	29	Std. Mean Difference (IV, Random, 95% CI)	‐0.76 [‐1.54, 0.02]
12 Severity of anxiety symptoms at 3–6 months Show forest plot	6	945	Std. Mean Difference (IV, Random, 95% CI)	‐0.05 [‐0.19, 0.10]

12.1 Supported psychoeducational intervention vs TAU	1	23	Std. Mean Difference (IV, Random, 95% CI)	‐0.15 [‐1.08, 0.78]
12.2 Self‐guided Internet‐based intervention vs TAU	1	300	Std. Mean Difference (IV, Random, 95% CI)	‐0.09 [‐0.32, 0.14]
12.3 Brief dyadic therapy vs TAU	1	29	Std. Mean Difference (IV, Random, 95% CI)	‐0.76 [‐1.54, 0.02]
12.4 Telephone‐based CBT	1	185	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
12.5 Communication facilitator in an intensive care setting vs usual care	1	162	Std. Mean Difference (IV, Random, 95% CI)	0.04 [‐0.27, 0.35]
12.6 Nurse‐led intensive care recovery programme vs TAU	1	246	Std. Mean Difference (IV, Random, 95% CI)	0.03 [‐0.22, 0.28]
13 Severity of anxiety symptoms at 7–12 months Show forest plot	3	746	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.27, 0.18]

13.1 Self‐guided Internet‐based intervention vs TAU	1	300	Std. Mean Difference (IV, Random, 95% CI)	0.09 [‐0.13, 0.32]
13.2 Telephone‐based CBT	1	185	Std. Mean Difference (IV, Random, 95% CI)	‐0.30 [‐0.59, ‐0.01]
13.3 Nurse‐led intensive care recovery programme vs TAU	1	261	Std. Mean Difference (IV, Random, 95% CI)	0.04 [‐0.21, 0.28]

Comparison 1. Any early psychological intervention versus waiting list/usual care

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Comparison 2. Any early psychological intervention versus active control condition

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Dropouts from treatment Show forest plot	2	425	Risk Ratio (M‐H, Random, 95% CI)	1.61 [1.11, 2.34]

1.1 Brief individual trauma processing therapy vs parenting support	1	262	Risk Ratio (M‐H, Random, 95% CI)	1.78 [1.12, 2.84]
1.2 Guided self‐help vs physical educational intervention	1	163	Risk Ratio (M‐H, Random, 95% CI)	1.33 [0.71, 2.50]
2 Severity of PTSD symptoms post‐treatment Show forest plot	2	392	Std. Mean Difference (IV, Random, 95% CI)	0.13 [‐0.06, 0.33]

2.1 Brief individual trauma processing therapy vs parenting support	1	217	Std. Mean Difference (IV, Random, 95% CI)	0.14 [‐0.13, 0.41]
2.2 Guided self‐help vs physical educational intervention	1	175	Std. Mean Difference (IV, Random, 95% CI)	0.13 [‐0.17, 0.42]
3 Severity of PTSD symptoms at 3–6 months Show forest plot	4	465	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.31, 0.26]

3.1 Brief individual trauma processing therapy vs supportive listening	2	51	Std. Mean Difference (IV, Random, 95% CI)	‐0.54 [‐1.42, 0.34]
3.2 Brief individual trauma processing therapy vs parenting support	1	239	Std. Mean Difference (IV, Random, 95% CI)	0.06 [‐0.19, 0.31]
3.3 Guided self‐help vs physical educational intervention	1	175	Std. Mean Difference (IV, Random, 95% CI)	0.13 [‐0.16, 0.43]
4 Severity of PTSD symptoms at 7–12 months Show forest plot	1	200	Mean Difference (IV, Random, 95% CI)	1.27 [‐0.60, 3.14]

4.1 Brief individual trauma processing therapy vs parenting support	1	200	Mean Difference (IV, Random, 95% CI)	1.27 [‐0.60, 3.14]
5 Severity of depression symptoms post‐treatment Show forest plot	2	392	Std. Mean Difference (IV, Random, 95% CI)	0.12 [‐0.08, 0.32]

5.1 Brief individual trauma processing therapy vs parenting support	1	217	Std. Mean Difference (IV, Random, 95% CI)	0.06 [‐0.21, 0.33]
5.2 Guided self‐help vs physical educational intervention	1	175	Std. Mean Difference (IV, Random, 95% CI)	0.19 [‐0.11, 0.49]
6 Severity of depressive symptoms at 3–6 months Show forest plot	2	409	Std. Mean Difference (IV, Random, 95% CI)	0.04 [‐0.16, 0.23]

6.1 Brief individual trauma processing therapy vs parenting support	1	234	Std. Mean Difference (IV, Random, 95% CI)	0.09 [‐0.17, 0.34]
6.2 Guided self‐help vs physical educational intervention	1	175	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.33, 0.26]
7 Severity of depressive symptoms at 7–12 months Show forest plot	1	198	Mean Difference (IV, Random, 95% CI)	0.79 [‐0.66, 2.24]

7.1 Brief individual trauma processing therapy vs parenting support	1	198	Mean Difference (IV, Random, 95% CI)	0.79 [‐0.66, 2.24]
8 Severity of anxiety symptoms post‐treatment Show forest plot	2	392	Std. Mean Difference (IV, Random, 95% CI)	0.08 [‐0.12, 0.28]

8.1 Brief individual trauma processing therapy vs parenting support	1	217	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.17, 0.37]
8.2 Guided self‐help vs physical educational intervention	1	175	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.24, 0.35]
9 Severity of anxiety symptoms at 3–6 months Show forest plot	2	414	Std. Mean Difference (IV, Random, 95% CI)	0.00 [‐0.19, 0.19]

9.1 Brief individual trauma processing therapy vs parenting support	1	239	Std. Mean Difference (IV, Random, 95% CI)	0.03 [‐0.22, 0.28]
9.2 Guided self‐help vs physical educational intervention	1	175	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.33, 0.26]
10 Severity of anxiety symptoms at 7–12 months Show forest plot	1	199	Mean Difference (IV, Random, 95% CI)	‐0.07 [‐1.58, 1.44]

10.1 Brief individual trauma processing therapy vs parenting support	1	199	Mean Difference (IV, Random, 95% CI)	‐0.07 [‐1.58, 1.44]
11 General functioning post‐treatment Show forest plot	1	218	Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.05, 0.01]

11.1 Brief individual trauma processing therapy vs parenting support	1	218	Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.05, 0.01]
12 General functioning at 3–6 months Show forest plot	1	239	Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.06, 0.00]

12.1 Brief individual trauma processing therapy vs parenting support	1	239	Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.06, 0.00]
13 General functioning at 7–12 months Show forest plot	1	199	Mean Difference (IV, Random, 95% CI)	0.01 [‐0.03, 0.05]

13.1 Brief individual trauma processing therapy vs parenting support	1	199	Mean Difference (IV, Random, 95% CI)	0.01 [‐0.03, 0.05]

Comparison 2. Any early psychological intervention versus active control condition

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Resumen

Antecedentes

Objetivos

Métodos de búsqueda

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Obtención y análisis de los datos

Resultados principales

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PICO

PICO

Population

Intervention

Comparison

Outcome

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Intervenciones psicológicas iniciales con sesiones múltiples para la prevención del trastorno por estrés postraumático

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Conclusiones de los autores

Implicaciones para la práctica

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Summary of findings

Antecedentes

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De qué manera podría funcionar la intervención

Por qué es importante realizar esta revisión

Objetivos

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Tipos de estudios

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Métodos de búsqueda para la identificación de los estudios

Búsquedas electrónicas

Cochrane Common Mental Disorders Controlled Trials Register (CCMD‐CTR)

Search one (1 August 2008)

Search two (6 May 2016)

Search three (3 March 2018)

Search four (15 March 2019)

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Medidas del efecto del tratamiento

Continuous data

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Evaluación de la heterogeneidad

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'Summary of findings' tables

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Participants

Interventions

Outcomes

Excluded studies

Studies awaiting classification

Ongoing studies

Risk of bias in included studies

Random sequence generation

Allocation concealment

Blinding of participants and personnel

Blinding of outcome assessors

Incomplete outcome data

Selective reporting