Discussion
trauma, PTSD, DSM-5, traumatic
EVENTS
To our knowledge, this is the first study to compare the efficacy of a trauma-focused and non-trauma-focused therapist-assisted online cognitive behavioural treatment for people with PTSD as diagnosed using DSM-5. iCT-PTSD, a novel treatment that incorporates all procedures of NICE recommended CT-PTSD,The advantage of iCT-PTSD over iStress-PTSD was maintained during follow-up. iCT-PTSD led to substantial and lasting reductions in PTSD symptoms and a wide range of other outcomes, including quality of life. For participants in the iCT-PTSD group, the standardised within-group effect sizes in reduction of PTSD symptoms of 2·22 at 13 weeks to 2·49 at 26 weeks and the proportion of participants who no longer met criteria for a DSM-5 PTSD diagnosis (84% of participants who completed the 13-week assessment and 72% of participants who were randomly assigned) are in line with those observed in RCTs for face-to-face CT-PTSD.Our results parallel the findings of meta-analyses for face-to-face psychological treatments for PTSDBoth treatments were efficacious and superior to waiting for treatment with usual NHS care. The comprehensiveness of the treatments, each implementing the same treatment procedures as for face-to-face therapy, and the quality and frequency of support provided by therapists is a probable factor in these results. Participants reported that they greatly valued their therapist's support through calls and messages, and the treatments were clearly acceptable to patients since satisfaction ratings were high and dropout rates were below 10%. This rate compares favourably with the mean dropout rate of 23% reported for therapist-assisted iCBTAlthough some clinicians might be concerned that remote delivery of a trauma-focused treatment could increase the probability of symptom deterioration, our findings suggest otherwise, as PTSD symptom deterioration occurred in about 10% of participants randomly assigned to waiting list with usual care and in none of the participants assigned to iCT-PTSD, replicating the findings for face-to-face CT-PTSD.The moderation analyses showed that the additional benefits for iCT-PTSD over iStress-PTSD were especially large for participants with high dissociation and self-reported complex PTSD symptoms, which contradicts any expectation that trauma-focused treatments might be less tolerable or less beneficial for people with severe presentations of PTSD.Four participants in the waiting list group no longer met full criteria for PTSD at the end of the waiting list period. In line with epidemiological data on natural recovery over time,The mediation analysis results support the importance of changing the psychological processes in the theoretical model that underpins CT-PTSD.Therapist-assisted online treatments provide convenience for patients because they can work on the treatment in a place and at a time that suits them. Several participants commented that they preferred doing therapy in their own time (This study had various limitations. Although iStress-PTSD was chosen to represent a non-trauma-focused treatment, it contains some trauma-related content, such as normalising the effects of traumatic events as stress reactions and the application of coping strategies to intrusive trauma memories. Some participants also used coping skills such as challenging their thoughts and exposure to trauma-related thoughts and situations, which contributed to the efficacy of iStress-PTSD and ensured the credibility of the treatment, but might have underestimated the difference between treatments. The analysis of treatment effects and their maintenance focused on group means, and a small group of individual participants showed different patterns such as deterioration or continued improvement during follow-up. Negative life events and the COVID-19 pandemic affected some participants’ treatment and assessments. In clinical practice, communication by phone calls and messages might not suit everyone, and therapists could consider offering a choice between video and phone calls, or blend iCT-PTSD modules with some face-to-face sessions.Overall, our results suggest that iCT-PTSD is a viable and promising alternative to face-to-face therapy for PTSD and could contribute to increasing patient choice, among other options such as other trauma-focused iCBT programmes.