Psychological therapies for children and adolescents exposed to trauma

Donna Gillies; Licia Maiocchi; Abhishta P Bhandari; Fiona Taylor; Carl Gray; Louise O'Brien

doi:10.1002/14651858.CD012371

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Figure 1

PRISMA study 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 All psychotherapies versus control (short‐term), outcome: 1.2 PTSD total symptoms.

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Analysis 1.1

Comparison 1 All psychotherapies versus control (short‐term), Outcome 1 PTSD diagnosis.

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Analysis 1.2

Comparison 1 All psychotherapies versus control (short‐term), Outcome 2 PTSD total symptoms.

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Analysis 1.3

Comparison 1 All psychotherapies versus control (short‐term), Outcome 3 PTSD avoidance.

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Analysis 1.4

Comparison 1 All psychotherapies versus control (short‐term), Outcome 4 PTSD hyperarousal.

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Analysis 1.5

Comparison 1 All psychotherapies versus control (short‐term), Outcome 5 PTSD intrusion.

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Analysis 1.6

Comparison 1 All psychotherapies versus control (short‐term), Outcome 6 Anxiety total symptoms.

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Analysis 1.7

Comparison 1 All psychotherapies versus control (short‐term), Outcome 7 Anxiety ‐ state.

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Analysis 1.8

Comparison 1 All psychotherapies versus control (short‐term), Outcome 8 Anxiety ‐ trait.

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Analysis 1.9

Comparison 1 All psychotherapies versus control (short‐term), Outcome 9 Depression.

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Analysis 1.10

Comparison 1 All psychotherapies versus control (short‐term), Outcome 10 Behaviour ‐ total.

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Analysis 1.11

Comparison 1 All psychotherapies versus control (short‐term), Outcome 11 Behaviour ‐ internalising.

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Analysis 1.12

Comparison 1 All psychotherapies versus control (short‐term), Outcome 12 Behaviour ‐ externalising.

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Analysis 1.13

Comparison 1 All psychotherapies versus control (short‐term), Outcome 13 Functional impairment.

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Analysis 1.14

Comparison 1 All psychotherapies versus control (short‐term), Outcome 14 Quality of life.

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Analysis 1.15

Comparison 1 All psychotherapies versus control (short‐term), Outcome 15 Loss to follow‐up.

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Analysis 2.1

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 1 PTSD diagnosis.

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Analysis 2.2

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 2 PTSD total symptoms.

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Analysis 2.3

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 3 PTSD ‐ avoidance.

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Analysis 2.4

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 4 PTSD ‐ hyperarousal.

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Analysis 2.5

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 5 PTSD ‐ intrusion.

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Analysis 2.6

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 6 Anxiety total symptoms.

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Analysis 2.7

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 7 Anxiety ‐ state.

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Analysis 2.8

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 8 Anxiety ‐ trait.

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Analysis 2.9

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 9 Depression.

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Analysis 2.10

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 10 Behaviour ‐ total.

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Analysis 2.11

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 11 Behaviour ‐ internalising.

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Analysis 2.12

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 12 Behaviour ‐ externalising.

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Analysis 2.13

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 13 Function.

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Analysis 2.14

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 14 Quality of life.

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Analysis 2.15

Comparison 2 All psychotherapies versus control (medium‐term), Outcome 15 Loss to follow‐up.

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Analysis 3.1

Comparison 3 All psychotherapies versus control (long‐term), Outcome 1 PTSD diagnosis.

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Analysis 3.2

Comparison 3 All psychotherapies versus control (long‐term), Outcome 2 PTSD total symptoms.

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Analysis 3.3

Comparison 3 All psychotherapies versus control (long‐term), Outcome 3 Anxiety.

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Analysis 3.4

Comparison 3 All psychotherapies versus control (long‐term), Outcome 4 Depression.

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Analysis 3.5

Comparison 3 All psychotherapies versus control (long‐term), Outcome 5 Behaviour ‐ total.

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Analysis 3.6

Comparison 3 All psychotherapies versus control (long‐term), Outcome 6 Behaviour ‐ internalising.

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Analysis 3.7

Comparison 3 All psychotherapies versus control (long‐term), Outcome 7 Behaviour ‐ externalising.

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Analysis 3.8

Comparison 3 All psychotherapies versus control (long‐term), Outcome 8 Loss to follow‐up.

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Analysis 4.1

Comparison 4 CBT versus other therapies (short‐term), Outcome 1 PTSD diagnosis.

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Analysis 4.2

Comparison 4 CBT versus other therapies (short‐term), Outcome 2 PTSD total symptoms.

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Analysis 4.3

Comparison 4 CBT versus other therapies (short‐term), Outcome 3 PTSD avoidance.

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Analysis 4.4

Comparison 4 CBT versus other therapies (short‐term), Outcome 4 PTSD hyperarousal.

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Analysis 4.5

Comparison 4 CBT versus other therapies (short‐term), Outcome 5 PTSD intrusion.

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Analysis 4.6

Comparison 4 CBT versus other therapies (short‐term), Outcome 6 Anxiety total symptoms.

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Analysis 4.7

Comparison 4 CBT versus other therapies (short‐term), Outcome 7 Depression.

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Analysis 4.8

Comparison 4 CBT versus other therapies (short‐term), Outcome 8 Behaviour ‐ total.

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Analysis 4.9

Comparison 4 CBT versus other therapies (short‐term), Outcome 9 Behaviour ‐ internalising.

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Analysis 4.10

Comparison 4 CBT versus other therapies (short‐term), Outcome 10 Behaviour ‐ externalising.

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Analysis 4.11

Comparison 4 CBT versus other therapies (short‐term), Outcome 11 Function.

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Analysis 4.12

Comparison 4 CBT versus other therapies (short‐term), Outcome 12 Loss to follow‐up.

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Analysis 5.1

Comparison 5 CBT versus other therapies (medium‐term), Outcome 1 PTSD total symptoms.

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Analysis 5.2

Comparison 5 CBT versus other therapies (medium‐term), Outcome 2 Anxiety total symptoms.

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Analysis 5.3

Comparison 5 CBT versus other therapies (medium‐term), Outcome 3 Depression.

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Analysis 5.4

Comparison 5 CBT versus other therapies (medium‐term), Outcome 4 Behaviour ‐ total.

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Analysis 5.5

Comparison 5 CBT versus other therapies (medium‐term), Outcome 5 Behaviour ‐ internalising.

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Analysis 5.6

Comparison 5 CBT versus other therapies (medium‐term), Outcome 6 Behaviour ‐ externalising.

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Analysis 5.7

Comparison 5 CBT versus other therapies (medium‐term), Outcome 7 Loss to follow‐up.

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Analysis 6.1

Comparison 6 CBT versus other therapies (long‐term), Outcome 1 Behaviour ‐ internalising.

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Analysis 6.2

Comparison 6 CBT versus other therapies (long‐term), Outcome 2 Behaviour ‐ externalising.

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Analysis 6.3

Comparison 6 CBT versus other therapies (long‐term), Outcome 3 Loss to follow‐up.

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Analysis 7.1

Comparison 7 Subgroup analysis: Individual versus group therapy, Outcome 1 PTSD total symptoms.

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Analysis 8.1

Comparison 8 Subgroup analysis: Child versus mother and child therapy, Outcome 1 PTSD total symptoms.

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Analysis 9.1

Comparison 9 Subgroup analysis: type of trauma, Outcome 1 PTSD diagnosis.

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Analysis 9.2

Comparison 9 Subgroup analysis: type of trauma, Outcome 2 PTSD total symptoms.

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Analysis 10.1

Comparison 10 Subgroup analysis: symptomatic participants, Outcome 1 PTSD diagnosis.

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Analysis 10.2

Comparison 10 Subgroup analysis: symptomatic participants, Outcome 2 PTSD total symptoms.

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Analysis 11.1

Comparison 11 Sensitivity analysis: type of control, Outcome 1 PTSD diagnosis.

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Analysis 11.2

Comparison 11 Sensitivity analysis: type of control, Outcome 2 PTSD total symptoms.

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Analysis 12.1

Comparison 12 Sensitivity analysis: best‐/worst‐case analysis, Outcome 1 PTSD diagnosis.

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Analysis 13.1

Comparison 13 Sensitivity analysis: cluster‐randomisation, Outcome 1 PTSD diagnosis.

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Analysis 13.2

Comparison 13 Sensitivity analysis: cluster‐randomisation, Outcome 2 PTSD total symptoms.

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Analysis 14.1

Comparison 14 Sensitivity analysis: performance bias, Outcome 1 PTSD diagnosis.

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Analysis 14.2

Comparison 14 Sensitivity analysis: performance bias, Outcome 2 PTSD total symptoms.

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Analysis 15.1

Comparison 15 Sensitivity analysis: detection bias, Outcome 1 PTSD diagnosis.

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Analysis 15.2

Comparison 15 Sensitivity analysis: detection bias, Outcome 2 PTSD total symptoms.

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Analysis 16.1

Comparison 16 Sensitivity analysis: attrition bias, Outcome 1 PTSD diagnosis.

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Analysis 16.2

Comparison 16 Sensitivity analysis: attrition bias, Outcome 2 PTSD total symptoms.

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Analysis 17.1

Comparison 17 Sensitivity analysis: selection bias, Outcome 1 PTSD diagnosis.

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Analysis 17.2

Comparison 17 Sensitivity analysis: selection bias, Outcome 2 PTSD total symptoms.

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Summary of findings for the main comparison. Psychological therapies versus wait list, treatment as usual or no treatment for children and adolescents exposed to trauma (short‐term)

Patient or population: children and adolescents exposed to trauma Setting: three hospitals and fourteen community/outpatient settings (including eight schools, a trauma clinic, child support services, foster care and youth support services) in the US (6), Australia (2), Democratic Republic of Congo (2), Israel (2), the Palestinian territories (2), Bosnia(1), Canada (1), and Indonesia (1). Intervention: all psychological therapies Comparison: control (short‐term)
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with control (short‐term)	Risk with all psychotherapies
PTSD diagnosis	Study population		OR 0.51 (0.34 to 0.77)	874 (5 studies)	⊕⊝⊝⊝ Very low^a,b,c
	367 per 1000	228 per 1000 (165 to 309)
	Moderate
	345 per 1000	212 per 1000 (152 to 288)
PTSD total symptoms	Mean PTSD total symptoms in the intervention group 0.42 standard deviations undefined fewer (0.61 fewer to 0.24 fewer)		Moderate effect size	2051 (15 studies)	⊕⊕⊝⊝ Low^d,e
*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI) CI: confidence interval; OR: odds ratio; RR: risk ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect but may be substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
^aParticipants are likely to have been aware of whether they received the active or inactive intervention in all studies, and diagnosis was based on self reported measures in 2 studies ^bSignificant difference between the 2 psychological therapies included in this analysis (i.e. CBT and family therapy) (I² = 69%) ^cOnly 3 included studies with a relatively small overall sample number of 352 ^dParticipants were likely to have been aware of whether they received active or inactive intervention in all but one study, and scores were based on self reported measures in 10 studies ^eSubstantial heterogeneity between different types of psychological therapy (I² = 71%)

Summary of findings for the main comparison. Psychological therapies versus wait list, treatment as usual or no treatment for children and adolescents exposed to trauma (short‐term)

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Summary of findings 2. CBT versus other psychological therapies for children and adolescents exposed to trauma (short‐term)

Patient or population: children and adolescents exposed to trauma Setting: All seven studies were done in community or outpatient settings including child trauma (2) or psychiatric (2) services, child support services (1), domestic violence service (1) and school (1) in the US (4), Netherlands (2), and Iran (1). Intervention: CBT Comparison: other psychological therapies (short‐term)
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	Numer of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with other therapies (short‐term)	Risk with CBT
PTSD diagnosis	Study population		OR 0.74 (0.29 to 1.91)	160 (2 studies)	⊕⊝⊝⊝ Very low^a,b
	141 per 1000	108 per 1000 (45 to 239)
	Moderate
	111 per 1000	85 per 1000 (35 to 193)
PTSD total symptoms	Mean PTSD total symptoms in the intervention group 0.24 standard deviations undefined fewer (0.42 fewer to 0.05 fewer)		Small effect size	466 (7 studies)	⊕⊕⊕⊝ Moderate^c
*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI) CI: confidence interval; OR: odds ratio; RR: risk ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
^aParticipants are likely to have been aware of whether they received active or inactive intervention in both studies, and diagnosis was based on self reported measures in both ^bOnly 2 included studies with a relatively small overall sample number of 287 ^cParticipants are likely to have been aware of whether they received active or inactive intervention in all studies, and scores were based on self reported measures in 4 studies

Summary of findings 2. CBT versus other psychological therapies for children and adolescents exposed to trauma (short‐term)

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Table 1. Data from Church 2012

Outcome	Group	n	Mean	SD
PTSD symptoms One month	Exposure therapy	8	3.38	2.60
PTSD symptoms One month	Control	8	31.38	3.84
Avoidance One month	Exposure therapy	8	2.88	2.62
Avoidance One month	Control	8	20.25	2.38
Intrusion One month	Exposure therapy	8	0.50	0.50
Intrusion One month	Control	8	11.13	2.93

Table 1. Data from Church 2012

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Table 2. Data from Damra 2014

Outcome	Group	n	Mean	SD
PTSD symptoms Post therapy	TF‐CBT	9	13.00	1.12
PTSD symptoms Post therapy	Control	9	24.20	1.54
PTSD symptoms 4 months	TF‐CBT	9	11.88	1.96
PTSD symptoms 4 months	Control	9	23.98	1.47

Table 2. Data from Damra 2014

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Table 3. Data from McMullen 2013

Outcome	Group	n	Mean	SD
PTSD symptoms Post therapy	TF‐CBT	24	10.6	4.5
PTSD symptoms Post therapy	Control	24	34.8	11.6
Conduct Problems Post therapy	TF‐CBT	24	0.7	0.9
Conduct Problems Post therapy	Control	24	7.1	7.0

Table 3. Data from McMullen 2013

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Comparison 1. All psychotherapies versus control (short‐term)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis Show forest plot	5	874	Odds Ratio (M‐H, Random, 95% CI)	0.51 [0.34, 0.77]

1.1 CBT	3	769	Odds Ratio (M‐H, Random, 95% CI)	0.59 [0.43, 0.80]
1.2 EMDR	1	40	Odds Ratio (M‐H, Random, 95% CI)	0.2 [0.01, 4.44]
1.3 Family therapy	1	65	Odds Ratio (M‐H, Random, 95% CI)	0.11 [0.02, 0.56]
2 PTSD total symptoms Show forest plot	15	2051	Std. Mean Difference (IV, Random, 95% CI)	‐0.42 [‐0.61, ‐0.24]

2.1 CBT	6	1329	Std. Mean Difference (IV, Random, 95% CI)	‐0.37 [‐0.55, ‐0.19]
2.2 EMDR	1	24	Std. Mean Difference (IV, Random, 95% CI)	‐0.77 [‐1.61, 0.06]
2.3 Family therapy	2	95	Std. Mean Difference (IV, Random, 95% CI)	‐0.53 [‐0.94, ‐0.12]
2.4 Narrative	1	64	Std. Mean Difference (IV, Random, 95% CI)	0.23 [‐0.26, 0.72]
2.5 Psychoeducation	2	215	Std. Mean Difference (IV, Random, 95% CI)	‐0.19 [‐0.69, 0.30]
2.6 Supportive therapy	2	272	Std. Mean Difference (IV, Random, 95% CI)	‐0.40 [‐0.95, 0.15]
2.7 CBT + narrative therapy	1	52	Std. Mean Difference (IV, Random, 95% CI)	‐1.96 [‐2.63, ‐1.29]
3 PTSD avoidance Show forest plot	2	205	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.29, 0.26]

3.1 Narrative	1	158	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.27, 0.36]
3.2 Psychoeducation	1	47	Std. Mean Difference (IV, Random, 95% CI)	‐0.23 [‐0.80, 0.35]
4 PTSD hyperarousal Show forest plot	2	205	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.22, 0.32]

4.1 Narrative	1	158	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.21, 0.41]
4.2 Psychoeducation	1	47	Std. Mean Difference (IV, Random, 95% CI)	‐0.12 [‐0.70, 0.45]
5 PTSD intrusion Show forest plot	2	205	Std. Mean Difference (IV, Random, 95% CI)	0.11 [‐0.16, 0.39]

5.1 Narrative	1	158	Std. Mean Difference (IV, Random, 95% CI)	0.15 [‐0.16, 0.46]
5.2 Psychoeducation	1	47	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.59, 0.55]
6 Anxiety total symptoms Show forest plot	7	959	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.26, 0.00]

6.1 CBT	2	557	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.30, 0.04]
6.2 Counselling	1	130	Std. Mean Difference (IV, Random, 95% CI)	‐0.20 [‐0.56, 0.16]
6.3 EMDR	1	40	Std. Mean Difference (IV, Random, 95% CI)	‐0.66 [‐1.30, ‐0.03]
6.4 Exposure	1	65	Std. Mean Difference (IV, Random, 95% CI)	0.01 [‐0.48, 0.51]
6.5 Narrative	1	111	Std. Mean Difference (IV, Random, 95% CI)	‐0.21 [‐0.58, 0.17]
6.6 Psychoeducation	1	56	Std. Mean Difference (IV, Random, 95% CI)	0.32 [‐0.21, 0.85]
7 Anxiety ‐ state Show forest plot	2	70	Std. Mean Difference (IV, Random, 95% CI)	‐0.64 [‐1.12, ‐0.16]

7.1 CBT	1	46	Std. Mean Difference (IV, Random, 95% CI)	‐0.71 [‐1.31, ‐0.12]
7.2 EMDR	1	24	Std. Mean Difference (IV, Random, 95% CI)	‐0.51 [‐1.33, 0.31]
8 Anxiety ‐ trait Show forest plot	2	70	Std. Mean Difference (IV, Random, 95% CI)	‐0.34 [‐0.81, 0.14]

8.1 CBT	1	46	Std. Mean Difference (IV, Random, 95% CI)	‐0.36 [‐0.94, 0.22]
8.2 EMDR	1	24	Std. Mean Difference (IV, Random, 95% CI)	‐0.29 [‐1.10, 0.51]
9 Depression Show forest plot	13	1569	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.30, 0.04]

9.1 CBT	6	1191	Std. Mean Difference (IV, Random, 95% CI)	‐0.21 [‐0.42, ‐0.00]
9.2 EMDR	2	64	Std. Mean Difference (IV, Random, 95% CI)	‐0.39 [‐1.41, 0.64]
9.3 Exposure	1	52	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.45, 0.65]
9.4 Family therapy	1	30	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.66, 0.77]
9.5 Narrative	2	176	Std. Mean Difference (IV, Random, 95% CI)	0.13 [‐0.52, 0.77]
9.6 Psychoeducation	1	56	Std. Mean Difference (IV, Random, 95% CI)	0.09 [‐0.43, 0.62]
10 Behaviour ‐ total Show forest plot	3	166	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.51, 0.42]

10.1 EMDR	1	24	Std. Mean Difference (IV, Random, 95% CI)	‐0.44 [‐1.25, 0.37]
10.2 Exposure	1	77	Std. Mean Difference (IV, Random, 95% CI)	0.34 [‐0.11, 0.80]
10.3 Family therapy	1	65	Std. Mean Difference (IV, Random, 95% CI)	‐0.23 [‐0.72, 0.26]
11 Behaviour ‐ internalising Show forest plot	10	719	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.20, 0.13]

11.1 CBT	2	162	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.44, 0.18]
11.2 EMDR	2	64	Std. Mean Difference (IV, Random, 95% CI)	‐0.57 [‐1.07, ‐0.07]
11.3 Exposure	1	77	Std. Mean Difference (IV, Random, 95% CI)	0.38 [‐0.08, 0.84]
11.4 Family therapy	1	30	Std. Mean Difference (IV, Random, 95% CI)	0.32 [‐0.40, 1.04]
11.5 Narrative	2	180	Std. Mean Difference (IV, Random, 95% CI)	0.12 [‐0.18, 0.41]
11.6 Psychoeducation	2	206	Std. Mean Difference (IV, Random, 95% CI)	‐0.11 [‐0.38, 0.17]
12 Behaviour ‐ externalising Show forest plot	12	1174	Std. Mean Difference (IV, Random, 95% CI)	‐0.10 [‐0.33, 0.14]

12.1 CBT	3	565	Std. Mean Difference (IV, Random, 95% CI)	‐0.11 [‐0.28, 0.06]
12.2 EMDR	2	64	Std. Mean Difference (IV, Random, 95% CI)	‐0.55 [‐1.19, 0.10]
12.3 Exposure	1	77	Std. Mean Difference (IV, Random, 95% CI)	0.49 [0.03, 0.95]
12.4 Family therapy	1	30	Std. Mean Difference (IV, Random, 95% CI)	0.23 [‐0.49, 0.95]
12.5 Narrative	2	180	Std. Mean Difference (IV, Random, 95% CI)	0.20 [‐0.41, 0.81]
12.6 Psychoeducation	2	206	Std. Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.52, 0.46]
12.7 CBT + narrative therapy	1	52	Std. Mean Difference (IV, Random, 95% CI)	‐1.06 [‐1.64, ‐0.47]
13 Functional impairment Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

13.1 CBT	2	557	Std. Mean Difference (IV, Random, 95% CI)	‐0.41 [‐0.59, ‐0.24]
14 Quality of life Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

14.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
15 Loss to follow‐up Show forest plot	26	3872	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.69, 1.39]

15.1 CBT	14	2913	Risk Ratio (M‐H, Random, 95% CI)	0.87 [0.47, 1.62]
15.2 Counselling	1	164	Risk Ratio (M‐H, Random, 95% CI)	0.56 [0.30, 1.03]
15.3 EMDR	2	92	Risk Ratio (M‐H, Random, 95% CI)	1.64 [0.48, 5.59]
15.4 Exposure	1	16	Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
15.5 Family therapy	2	105	Risk Ratio (M‐H, Random, 95% CI)	1.44 [0.48, 4.30]
15.6 Narrative	2	280	Risk Ratio (M‐H, Random, 95% CI)	0.87 [0.32, 2.39]
15.7 Psychoeducation	3	274	Risk Ratio (M‐H, Random, 95% CI)	1.21 [0.75, 1.96]
15.8 Psychodrama	1	28	Risk Ratio (M‐H, Random, 95% CI)	1.5 [0.29, 7.65]

Comparison 1. All psychotherapies versus control (short‐term)

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Comparison 2. All psychotherapies versus control (medium‐term)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis Show forest plot	4	742	Odds Ratio (M‐H, Random, 95% CI)	0.66 [0.26, 1.69]

1.1 CBT	2	570	Odds Ratio (M‐H, Random, 95% CI)	0.49 [0.09, 2.61]
1.2 Debriefing	1	132	Odds Ratio (M‐H, Random, 95% CI)	1.31 [0.47, 3.68]
1.3 EMDR	1	40	Odds Ratio (M‐H, Random, 95% CI)	0.35 [0.01, 9.13]
2 PTSD total symptoms Show forest plot	12	2337	Std. Mean Difference (IV, Random, 95% CI)	‐0.17 [‐0.38, 0.05]

2.1 CBT	5	1701	Std. Mean Difference (IV, Random, 95% CI)	‐0.34 [‐0.72, 0.03]
2.2 Debriefing	2	231	Std. Mean Difference (IV, Random, 95% CI)	0.04 [‐0.22, 0.30]
2.3 Family therapy	2	141	Std. Mean Difference (IV, Random, 95% CI)	‐0.06 [‐0.39, 0.27]
2.4 Narrative	1	64	Std. Mean Difference (IV, Random, 95% CI)	0.23 [‐0.26, 0.73]
2.5 Psychoeducation	1	56	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.65, 0.40]
2.6 Supportive therapy	1	144	Std. Mean Difference (IV, Random, 95% CI)	‐0.21 [‐0.54, 0.12]
3 PTSD ‐ avoidance Show forest plot	2	243	Std. Mean Difference (IV, Fixed, 95% CI)	0.04 [‐0.22, 0.29]

3.1 Debriefing	1	132	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.08 [‐0.42, 0.26]
3.2 Family therapy	1	111	Std. Mean Difference (IV, Fixed, 95% CI)	0.18 [‐0.20, 0.55]
4 PTSD ‐ hyperarousal Show forest plot	2	243	Std. Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.43, 0.17]

4.1 Debriefing	1	132	Std. Mean Difference (IV, Random, 95% CI)	0.01 [‐0.33, 0.35]
4.2 Family therapy	1	111	Std. Mean Difference (IV, Random, 95% CI)	‐0.29 [‐0.67, 0.09]
5 PTSD ‐ intrusion Show forest plot	2	243	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.04 [‐0.29, 0.21]

5.1 Debriefing	1	132	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.05 [‐0.39, 0.29]
5.2 Family therapy	1	111	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.03 [‐0.40, 0.35]
6 Anxiety total symptoms Show forest plot	7	1470	Std. Mean Difference (IV, Random, 95% CI)	‐0.10 [‐0.20, 0.00]

6.1 CBT	3	1131	Std. Mean Difference (IV, Random, 95% CI)	‐0.07 [‐0.19, 0.04]
6.2 Debriefing	1	132	Std. Mean Difference (IV, Random, 95% CI)	‐0.08 [‐0.42, 0.27]
6.3 EMDR	1	40	Std. Mean Difference (IV, Random, 95% CI)	‐0.72 [‐1.36, ‐0.07]
6.4 Psychoeducation	1	56	Std. Mean Difference (IV, Random, 95% CI)	‐0.21 [‐0.73, 0.32]
6.5 Narrative	1	111	Std. Mean Difference (IV, Random, 95% CI)	‐0.17 [‐0.54, 0.21]
7 Anxiety ‐ state Show forest plot	1		Std. Mean Difference (IV, Fixed, 95% CI)	Totals not selected

7.1 CBT	1		Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Anxiety ‐ trait Show forest plot	2		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only

8.1 CBT	2	101	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.45 [‐0.85, ‐0.05]
9 Depression Show forest plot	13	2191	Std. Mean Difference (IV, Random, 95% CI)	‐0.07 [‐0.22, 0.07]

9.1 CBT	8	1810	Std. Mean Difference (IV, Random, 95% CI)	‐0.12 [‐0.31, 0.07]
9.2 Debriefing	2	231	Std. Mean Difference (IV, Random, 95% CI)	‐0.12 [‐0.38, 0.14]
9.3 Family therapy	1	30	Std. Mean Difference (IV, Random, 95% CI)	0.34 [‐0.38, 1.06]
9.4 Narrative	1	64	Std. Mean Difference (IV, Random, 95% CI)	0.34 [‐0.15, 0.84]
9.5 Psychoeducation	1	56	Std. Mean Difference (IV, Random, 95% CI)	‐0.14 [‐0.67, 0.38]
10 Behaviour ‐ total Show forest plot	3	281	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.20 [‐0.43, 0.04]

10.1 Debriefing	1	132	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.28 [‐0.62, 0.06]
10.2 Family therapy	1	50	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.37 [‐0.93, 0.19]
10.3 Narrative	1	99	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.39, 0.39]
11 Behaviour ‐ internalising Show forest plot	4	291	Std. Mean Difference (IV, Random, 95% CI)	0.01 [‐0.25, 0.28]

11.1 EMDR	1	40	Std. Mean Difference (IV, Random, 95% CI)	‐0.50 [‐1.13, 0.14]
11.2 Family therapy	1	30	Std. Mean Difference (IV, Random, 95% CI)	0.0 [‐0.72, 0.72]
11.3 Narrative	2	221	Std. Mean Difference (IV, Random, 95% CI)	0.13 [‐0.13, 0.40]
12 Behaviour ‐ externalising Show forest plot	5	694	Std. Mean Difference (IV, Random, 95% CI)	0.02 [‐0.32, 0.35]

12.1 CBT	1	403	Std. Mean Difference (IV, Random, 95% CI)	0.07 [‐0.13, 0.27]
12.2 EMDR	1	40	Std. Mean Difference (IV, Random, 95% CI)	1.00 [‐1.66, ‐0.33]
12.3 Family therapy	1	30	Std. Mean Difference (IV, Random, 95% CI)	‐0.01 [‐0.72, 0.71]
12.4 Narrative	2	221	Std. Mean Difference (IV, Random, 95% CI)	0.31 [0.05, 0.58]
13 Function Show forest plot	3		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

13.1 CBT	3	814	Std. Mean Difference (IV, Random, 95% CI)	‐0.46 [‐0.88, ‐0.05]
14 Quality of life Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

14.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
15 Loss to follow‐up Show forest plot	20	3663	Odds Ratio (M‐H, Fixed, 95% CI)	1.00 [0.82, 1.21]

15.1 CBT	11	2856	Odds Ratio (M‐H, Fixed, 95% CI)	1.01 [0.81, 1.27]
15.2 Counselling	1	23	Odds Ratio (M‐H, Fixed, 95% CI)	7.0 [0.32, 152.95]
15.3 Debriefing	1	158	Odds Ratio (M‐H, Fixed, 95% CI)	0.76 [0.33, 1.76]
15.4 EMDR	1	65	Odds Ratio (M‐H, Fixed, 95% CI)	1.41 [0.52, 3.84]
15.5 Family therapy	1	75	Odds Ratio (M‐H, Fixed, 95% CI)	1.28 [0.48, 3.39]
15.6 Narrative	2	171	Odds Ratio (M‐H, Fixed, 95% CI)	0.70 [0.16, 2.99]
15.7 Psychoeducation	2	244	Odds Ratio (M‐H, Fixed, 95% CI)	0.77 [0.40, 1.47]
15.8 Other	1	71	Odds Ratio (M‐H, Fixed, 95% CI)	0.90 [0.29, 2.73]

Comparison 2. All psychotherapies versus control (medium‐term)

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Comparison 3. All psychotherapies versus control (long‐term)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis Show forest plot	1		Odds Ratio (M‐H, Random, 95% CI)	Totals not selected

1.1 Narrative	1		Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
2 PTSD total symptoms Show forest plot	2	141	Std. Mean Difference (IV, Random, 95% CI)	0.17 [‐0.28, 0.62]

2.1 Exposure	1	77	Std. Mean Difference (IV, Random, 95% CI)	0.39 [‐0.07, 0.85]
2.2 Narrative	1	64	Std. Mean Difference (IV, Random, 95% CI)	‐0.07 [‐0.56, 0.42]
3 Anxiety Show forest plot	2	176	Std. Mean Difference (IV, Random, 95% CI)	‐0.12 [‐0.41, 0.18]

3.1 Exposure	1	65	Std. Mean Difference (IV, Random, 95% CI)	‐0.30 [‐0.80, 0.19]
3.2 Narrative	1	111	Std. Mean Difference (IV, Random, 95% CI)	‐0.01 [‐0.39, 0.36]
4 Depression Show forest plot	3	152	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.24 [‐0.56, 0.08]

4.1 CBT	1	36	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.59 [‐1.27, 0.09]
4.2 Exposure	1	52	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.29 [‐0.84, 0.26]
4.3 Narrative	1	64	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.02 [‐0.51, 0.47]
5 Behaviour ‐ total Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

5.1 Exposure	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
6 Behaviour ‐ internalising Show forest plot	2	141	Std. Mean Difference (IV, Random, 95% CI)	0.04 [‐0.51, 0.59]

6.1 Exposure	1	77	Std. Mean Difference (IV, Random, 95% CI)	0.31 [‐0.15, 0.77]
6.2 Narrative	1	64	Std. Mean Difference (IV, Random, 95% CI)	‐0.25 [‐0.75, 0.24]
7 Behaviour ‐ externalising Show forest plot	3	298	Std. Mean Difference (IV, Random, 95% CI)	0.28 [‐0.05, 0.60]

7.1 Exposure	1	77	Std. Mean Difference (IV, Random, 95% CI)	0.51 [0.04, 0.97]
7.2 Narrative	2	221	Std. Mean Difference (IV, Random, 95% CI)	0.17 [‐0.30, 0.64]
8 Loss to follow‐up Show forest plot	2	120	Odds Ratio (M‐H, Random, 95% CI)	0.45 [0.15, 1.32]

8.1 CBT	1	50	Odds Ratio (M‐H, Random, 95% CI)	0.29 [0.08, 1.09]
8.2 Narrative	1	70	Odds Ratio (M‐H, Random, 95% CI)	0.88 [0.17, 4.71]

Comparison 3. All psychotherapies versus control (long‐term)

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Comparison 4. CBT versus other therapies (short‐term)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis Show forest plot	2	160	Odds Ratio (M‐H, Random, 95% CI)	0.74 [0.29, 1.91]

1.1 EMDR	1	36	Odds Ratio (M‐H, Random, 95% CI)	1.0 [0.06, 17.33]
1.2 Supportive therapy	1	124	Odds Ratio (M‐H, Random, 95% CI)	0.71 [0.26, 1.95]
2 PTSD total symptoms Show forest plot	7	466	Std. Mean Difference (IV, Random, 95% CI)	‐0.24 [‐0.42, ‐0.05]

2.1 EMDR	2	62	Std. Mean Difference (IV, Random, 95% CI)	0.06 [‐0.44, 0.56]
2.2 Play therapy	1	26	Std. Mean Difference (IV, Random, 95% CI)	0.21 [‐0.56, 0.98]
2.3 Supportive therapies	4	378	Std. Mean Difference (IV, Random, 95% CI)	‐0.32 [‐0.53, ‐0.12]
3 PTSD avoidance Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

3.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 PTSD hyperarousal Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

4.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5 PTSD intrusion Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

5.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
6 Anxiety total symptoms Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

6.1 Supportive therapy	2	230	Std. Mean Difference (IV, Random, 95% CI)	‐0.48 [‐0.74, ‐0.22]
7 Depression Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

7.1 Supportive therapy	2	237	Std. Mean Difference (IV, Random, 95% CI)	‐0.14 [‐0.42, 0.14]
8 Behaviour ‐ total Show forest plot	3	182	Std. Mean Difference (IV, Random, 95% CI)	0.02 [‐0.27, 0.31]

8.1 EMDR	1	14	Std. Mean Difference (IV, Random, 95% CI)	‐0.44 [‐1.50, 0.63]
8.2 Supportive therapy	2	168	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.25, 0.36]
9 Behaviour ‐ internalising Show forest plot	3		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

9.1 Supportive therapy	3	235	Std. Mean Difference (IV, Random, 95% CI)	‐0.25 [‐0.79, 0.28]
10 Behaviour ‐ externalising Show forest plot	3		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

10.1 Supportive therapy	3	235	Std. Mean Difference (IV, Random, 95% CI)	‐0.31 [‐0.58, ‐0.05]
11 Function Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

11.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
12 Loss to follow‐up Show forest plot	8	544	Odds Ratio (M‐H, Random, 95% CI)	0.69 [0.41, 1.18]

12.1 EMDR	2	64	Odds Ratio (M‐H, Random, 95% CI)	0.76 [0.23, 2.52]
12.2 Play therapy	1	31	Odds Ratio (M‐H, Random, 95% CI)	0.08 [0.00, 1.56]
12.3 Supportive therapy	5	449	Odds Ratio (M‐H, Random, 95% CI)	0.74 [0.38, 1.43]

Comparison 4. CBT versus other therapies (short‐term)

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Comparison 5. CBT versus other therapies (medium‐term)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD total symptoms Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Supportive therapy	2	223	Std. Mean Difference (IV, Random, 95% CI)	‐0.16 [‐0.43, 0.11]
2 Anxiety total symptoms Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Depression Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

3.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Behaviour ‐ total Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

4.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5 Behaviour ‐ internalising Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

5.1 Supportive therapy	2	178	Std. Mean Difference (IV, Random, 95% CI)	‐0.05 [‐0.36, 0.26]
6 Behaviour ‐ externalising Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

6.1 Supportive therapy	2	178	Std. Mean Difference (IV, Random, 95% CI)	‐0.06 [‐0.37, 0.25]
7 Loss to follow‐up Show forest plot	1		Odds Ratio (M‐H, Random, 95% CI)	Totals not selected

7.1 Supportive therapy	1		Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 5. CBT versus other therapies (medium‐term)

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Comparison 6. CBT versus other therapies (long‐term)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Behaviour ‐ internalising Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Behaviour ‐ externalising Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Supportive therapy	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Loss to follow‐up Show forest plot	1		Odds Ratio (M‐H, Random, 95% CI)	Totals not selected

3.1 Supportive therapy	1		Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 6. CBT versus other therapies (long‐term)

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Comparison 7. Subgroup analysis: Individual versus group therapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD total symptoms Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Short‐term	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 7. Subgroup analysis: Individual versus group therapy

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Comparison 8. Subgroup analysis: Child versus mother and child therapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD total symptoms Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Short‐term	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Medium‐term	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 Long‐term	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 8. Subgroup analysis: Child versus mother and child therapy

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Comparison 9. Subgroup analysis: type of trauma

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis Show forest plot	6		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Community violence	3	769	Odds Ratio (M‐H, Random, 95% CI)	0.59 [0.43, 0.80]
1.2 Interpersonal violence	1	65	Odds Ratio (M‐H, Random, 95% CI)	0.11 [0.02, 0.56]
1.3 Natural disaster	1	166	Odds Ratio (M‐H, Random, 95% CI)	0.16 [0.06, 0.45]
1.4 Physical trauma	1	132	Odds Ratio (M‐H, Random, 95% CI)	1.31 [0.47, 3.68]
2 PTSD total symptoms Show forest plot	18		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Community violence	8	2170	Std. Mean Difference (IV, Random, 95% CI)	‐0.24 [‐0.41, ‐0.06]
2.2 Interpersonal violence	1	65	Std. Mean Difference (IV, Random, 95% CI)	‐0.61 [‐1.11, ‐0.11]
2.3 Life‐threatening illness	1	111	Std. Mean Difference (IV, Random, 95% CI)	‐0.12 [‐0.50, 0.26]
2.4 Maltreatment	1	142	Std. Mean Difference (IV, Random, 95% CI)	‐0.12 [‐0.45, 0.21]
2.5 Natural disaster	1	166	Std. Mean Difference (IV, Random, 95% CI)	‐1.27 [‐1.60, ‐0.94]
2.6 Physical trauma	4	311	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.29, 0.26]
2.7 Sexual abuse	2	76	Std. Mean Difference (IV, Random, 95% CI)	‐0.67 [‐1.18, ‐0.16]

Comparison 9. Subgroup analysis: type of trauma

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Comparison 10. Subgroup analysis: symptomatic participants

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis Show forest plot	7		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Symptoms not stated	5	999	Odds Ratio (M‐H, Random, 95% CI)	0.41 [0.20, 0.83]
1.2 Symptomatic	2	197	Odds Ratio (M‐H, Random, 95% CI)	0.64 [0.32, 1.25]
2 PTSD total symptoms Show forest plot	21		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Symptoms not stated	12	1648	Std. Mean Difference (IV, Random, 95% CI)	‐0.41 [‐0.68, ‐0.13]
2.2 Symptomatic	9	1639	Std. Mean Difference (IV, Random, 95% CI)	‐0.30 [‐0.53, ‐0.06]

Comparison 10. Subgroup analysis: symptomatic participants

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Comparison 11. Sensitivity analysis: type of control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis Show forest plot	7		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Inactive control	5	1067	Odds Ratio (M‐H, Random, 95% CI)	0.53 [0.32, 0.88]
1.2 Active control	2	129	Odds Ratio (M‐H, Random, 95% CI)	0.23 [0.05, 1.14]
2 PTSD total symptoms Show forest plot	21		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Inactive control	15	2856	Std. Mean Difference (IV, Random, 95% CI)	‐0.40 [‐0.61, ‐0.19]
2.2 Active control	6	431	Std. Mean Difference (IV, Random, 95% CI)	‐0.25 [‐0.58, 0.09]

Comparison 11. Sensitivity analysis: type of control

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Comparison 12. Sensitivity analysis: best‐/worst‐case analysis

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis Show forest plot	7		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Best case	7	1282	Odds Ratio (M‐H, Random, 95% CI)	0.52 [0.28, 0.99]
1.2 Worst case	7	1252	Odds Ratio (M‐H, Random, 95% CI)	0.64 [0.42, 0.98]

Comparison 12. Sensitivity analysis: best‐/worst‐case analysis

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Comparison 13. Sensitivity analysis: cluster‐randomisation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis Show forest plot	7		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Cluster‐randomised	4	935	Odds Ratio (M‐H, Random, 95% CI)	0.46 [0.27, 0.76]
1.2 Individuals randomised	3	261	Odds Ratio (M‐H, Random, 95% CI)	0.47 [0.10, 2.19]
2 PTSD total symptoms Show forest plot	20		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Cluster‐randomised	7	2063	Std. Mean Difference (IV, Random, 95% CI)	‐0.40 [‐0.71, ‐0.10]
2.2 Individuals randomised	13	1172	Std. Mean Difference (IV, Random, 95% CI)	‐0.22 [‐0.38, ‐0.06]

Comparison 13. Sensitivity analysis: cluster‐randomisation

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Comparison 14. Sensitivity analysis: performance bias

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis Show forest plot	7		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Unclear risk	1	64	Odds Ratio (M‐H, Random, 95% CI)	0.56 [0.09, 3.62]
1.2 High risk	6	1132	Odds Ratio (M‐H, Random, 95% CI)	0.46 [0.27, 0.79]
2 PTSD total symptoms Show forest plot	21		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Unclear risk	1	64	Std. Mean Difference (IV, Random, 95% CI)	0.23 [‐0.26, 0.72]
2.2 High risk	20	3223	Std. Mean Difference (IV, Random, 95% CI)	‐0.39 [‐0.57, ‐0.20]

Comparison 14. Sensitivity analysis: performance bias

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Comparison 15. Sensitivity analysis: detection bias

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis Show forest plot	7		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Low risk	2	197	Odds Ratio (M‐H, Random, 95% CI)	0.41 [0.04, 4.68]
1.2 Unclear risk	1	64	Odds Ratio (M‐H, Random, 95% CI)	0.56 [0.09, 3.62]
1.3 High risk	4	935	Odds Ratio (M‐H, Random, 95% CI)	0.46 [0.27, 0.76]
2 PTSD total symptoms Show forest plot	21		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Low risk	1	132	Std. Mean Difference (IV, Random, 95% CI)	‐0.05 [‐0.39, 0.30]
2.2 Unclear risk	2	191	Std. Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.46, 0.40]
2.3 High risk	18	2964	Std. Mean Difference (IV, Random, 95% CI)	‐0.42 [‐0.62, ‐0.22]

Comparison 15. Sensitivity analysis: detection bias

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Comparison 16. Sensitivity analysis: attrition bias

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis Show forest plot	7		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Low risk	2	320	Odds Ratio (M‐H, Random, 95% CI)	0.27 [0.11, 0.65]
1.2 Unclear risk	3	329	Odds Ratio (M‐H, Random, 95% CI)	0.79 [0.45, 1.38]
1.3 High risk	2	547	Odds Ratio (M‐H, Random, 95% CI)	0.32 [0.06, 1.60]
2 PTSD total symptoms Show forest plot	21		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Low risk	7	1410	Std. Mean Difference (IV, Random, 95% CI)	‐0.38 [‐0.75, ‐0.01]
2.2 Unclear risk	9	1046	Std. Mean Difference (IV, Random, 95% CI)	‐0.36 [‐0.67, ‐0.05]
2.3 High risk	5	831	Std. Mean Difference (IV, Random, 95% CI)	‐0.30 [‐0.53, ‐0.06]

Comparison 16. Sensitivity analysis: attrition bias

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Comparison 17. Sensitivity analysis: selection bias

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PTSD diagnosis Show forest plot	7		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Low risk	4	516	Odds Ratio (M‐H, Random, 95% CI)	0.46 [0.18, 1.15]
1.2 Unclear risk	2	547	Odds Ratio (M‐H, Random, 95% CI)	0.32 [0.06, 1.60]
1.3 High risk	1	133	Odds Ratio (M‐H, Random, 95% CI)	0.65 [0.32, 1.33]
2 PTSD total symptoms Show forest plot	21		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Low risk	8	874	Std. Mean Difference (IV, Random, 95% CI)	‐0.57 [‐0.97, ‐0.17]
2.2 Unclear risk	13	2413	Std. Mean Difference (IV, Random, 95% CI)	‐0.22 [‐0.39, ‐0.06]

Comparison 17. Sensitivity analysis: selection bias

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