Research in context
Anxiety, anxiety, depression, post-traumatic stress disorder, PTSD, flashback, Depression, trauma
ADVERSE EFFECTS

Face-to-face, individual, trauma-focused cognitive behaviour therapy (CBT) has been shown to be highly effective in randomised controlled trials, and evidence supports it as a first-line treatment for post-traumatic stress disorder (PTSD), although face-to-face non-trauma-focused CBT has also shown good outcomes in the short term. However, many people with PTSD cannot access these treatments due to a shortage of trained therapists, their geographical location, or being unable to attend during usual office hours. Internet-delivered CBT (iCBT) could help to improve access and reduce therapist time. Several iCBT programmes for PTSD implement some of the trauma-focused CBT procedures, and a 2021 Cochrane review found that these programmes lead to moderately better outcomes than waiting lists (
To our knowledge, this is the first study directly comparing a trauma-focused therapist-assisted iCBT programme with a comprehensive non-trauma-focused iCBT programme in people with PTSD. iCT-PTSD, which faithfully implements all the procedures of the corresponding first-line treatments for PTSD recommended by UK National Institute for Health and Care Excellence (NICE), and iStress-PTSD, a comprehensive programme focusing on strategies for coping with stress and PTSD symptoms were both acceptable and credible to patients and were efficacious compared with waiting list plus usual UK National Health Service (NHS) care. iCT-PTSD was superior to an internet-based stress management therapy for PTSD (iStress-PTSD) in symptoms of PTSD and other outcomes including quality of life. Both treatments were shown to work by changing negative meanings of the trauma, unhelpful coping, and flashback memories. iCT-PTSD achieved comparable recovery rates to those found for face-to-face CT-PTSD in previous randomised trials and better recovery rates (77%) than currently observed in Improving Access to Psychological Therapies services (41% for 2021–22).
The superiority of trauma-focused iCBT-PTSD to the non-trauma-focused iCBT-PTSD suggests that specific work on trauma memories, their meanings, and their triggers has added benefits compared to good generic non-trauma-focused iCBT. We found that iStress-PTSD participants who chose trauma-related hierarchies for their exposure practice had better outcomes, which is in line with the added benefits of trauma-focused work. iCT-PTSD is an efficacious treatment that could help to make a first-line treatment recommended by NICE more widely accessible to patients, save more than half of the therapist's time, and help improve recovery rates in routine clinical care, such as NHS Talking Therapies for Anxiety and Depression (formerly Improving Access to Psychological Therapies) services, through consistent delivery of all core treatment procedures.Many people with PTSD are unable to access effective psychological treatments for a range of reasons, such as a shortage of therapists or being unable to attend therapy during usual working hours. It is therefore desirable to develop efficient forms of treatment delivery that can be more easily accessed than currently. Therapist-assisted, internet-based treatment delivery appears to be a promising option. There is evidence that therapist-assisted, internet-based psychological treatments are effective for PTSD. A 2021 Cochrane reviewIt remains unclear which types of internet-based treatments for PTSD work best and are most acceptable to patients, and whether a trauma-focused approach is advantageous for internet-based treatment. This study compared a novel trauma-focused, therapist-assisted online psychological therapy (internet-based cognitive therapy for PTSD [iCT-PTSD]We aimed to assess whether iCT-PTSD was superior to iStress-PTSD in reducing symptoms of PTSD; whether iCT-PTSD and iStress-PTSD are efficacious in leading to greater reduction in PTSD symptoms than being on a waiting list while receiving usual NHS care. We also aimed to assess whether iCT-PTSD leads to greater improvement in depression, anxiety, wellbeing, disability, quality of life, and sleep problems than iStress-PTSD, and whether iCT-PTSD and iStress-PTSD lead to greater improvements in those outcomes than the waiting list control. Through process analyses, we also aimed to investigate the acceptability and compliance with the treatments among participants, any adverse effects, and moderators and mediators of outcome.