Abstract
Background: Military and Veteran populations experience higher rates of posttraumatic stress disorder (PTSD) compared to civilians. While trauma focused psychotherapies are generally recommended as first-line treatments, the effectiveness of various treatments in military populations requires further investigation.
Objective: This meta-analysis aims to synthesize the current literature regarding effectiveness of psychotherapies, pharmacotherapies, and combination treatments for PTSD in military populations.
Data Sources: This preregistered review (PROSPERO: CRD42021245754) was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta Analyses and Cochrane guidelines. A search was conducted using PsycINFO, MEDLINE, Embase, CINAHL, and ProQuest Dissertations and Theses.
Study Selection: The final sample included data from 414 studies.
Data Extraction: Full study methodologies can be found in the published protocol (Liu et al, 2021).
Results: The pooled random-effects model found effect size across all PTSD treatments (k = 712) was g=0.96, compared to g=0.45 for control conditions (k = 122). Clinician administered measures indicated larger treatment effects (g= 1.02) than self reported measures (g =0.82). Combination therapies yielded the largest effects (g =2.17), outperforming both psychotherapies and pharmacotherapies alone. No significant differences were found across control conditions.
Conclusion: Findings suggest that integrating psychotherapies and pharmacotherapies may address multiple dimensions of PTSD more effectively than monotherapies. However, these results contrast with the prioritization of trauma-informed psychotherapies over pharmacotherapies, as recommended by the 2023 US Department of Veterans Affairs/Department of Defense guidelines. Future research should focus on subclass analyses and long-term outcomes to refine treatment strategies for PTSD in military populations. Tailoring treatment plans to individual needs remains crucial for optimizing recovery and long-term symptom management.
J Clin Psychiatry 2025;86(2):24r15571
Author affiliations are listed at the end of this article.
Abstract
Background: Military and Veteran populations experience higher rates of posttraumatic stress disorder (PTSD) compared to civilians. While trauma focused psychotherapies are generally recommended as first-line treatments, the effectiveness of various treatments in military populations requires further investigation.
Objective: This meta-analysis aims to synthesize the current literature regarding effectiveness of psychotherapies, pharmacotherapies, and combination treatments for PTSD in military populations.
Data Sources: This preregistered review (PROSPERO: CRD42021245754) was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta Analyses and Cochrane guidelines. A search was conducted using PsycINFO, MEDLINE, Embase, CINAHL, and ProQuest Dissertations and Theses.
Study Selection: The final sample included data from 414 studies.
Data Extraction: Full study methodologies can be found in the published protocol (Liu et al, 2021).
Results: The pooled random-effects model found effect size across all PTSD treatments (k = 712) was g=0.96, compared to g=0.45 for control conditions (k = 122). Clinician administered measures indicated larger treatment effects (g= 1.02) than self reported measures (g =0.82). Combination therapies yielded the largest effects (g =2.17), outperforming both psychotherapies and pharmacotherapies alone. No significant differences were found across control conditions.
Conclusion: Findings suggest that integrating psychotherapies and pharmacotherapies may address multiple dimensions of PTSD more effectively than monotherapies. However, these results contrast with the prioritization of trauma-informed psychotherapies over pharmacotherapies, as recommended by the 2023 US Department of Veterans Affairs/Department of Defense guidelines. Future research should focus on subclass analyses and long-term outcomes to refine treatment strategies for PTSD in military populations. Tailoring treatment plans to individual needs remains crucial for optimizing recovery and long-term symptom management.
J Clin Psychiatry 2025;86(2):24r15571
Author affiliations are listed at the end of this article.
This content is restricted to subscribers
References (40)
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5, Text Revision. 5th ed. Text Rev. American Psychiatric Publishing; 2022.
- World Health Organization (WHO). International Classification of Diseases: 11th Revision (ICD-11). World Health Organization; 2022. Accessed April 14, 2021. https://icd.who.int/en.
- Wisco BE, Marx BP, Wolf EJ, et al. Posttraumatic stress disorder in the US veteran population: results from the National Health and Resilience in Veterans Study. J Clin Psychiatry. 2014;75(12):1338–1346. PubMed CrossRef
- Leon MR, Osburn HK, Bellairs T. Processing war: similarities and differences in PTSD antecedents and outcomes between military and civilian war survivors. In: Harms PD, Perrewé PL, eds. Occupational Stress and Well-being in Military Contexts. 16. Emerald Publishing Limited;2018:1–22. CrossRef
- Bisson JI, Ehlers A, Matthews R, et al. Psychological treatments for chronic post traumatic stress disorder: systematic review and meta-analysis. Br J Psychiatry. 2007;190(2):97–104. PubMed CrossRef
- Bradley R, Greene J, Russ E, et al. A multidimensional meta-analysis of psychotherapy for PTSD. Am J Psychiatry. 2005;162(2):214–227. PubMed CrossRef
- Lee DJ, Schnitzlein CW, Wolf JP, et al. Psychotherapy versus pharmacotherapy for posttraumatic stress disorder: systematic review and meta-analyses to determine first-line treatments. Depress Anxiety. 2016;33(9):792–806.
- VA/DoD Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder. VA/DoD Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder. U.S. Government Printing Office; 2023.
- American Psychological Association. Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults. American Psychological Association; 2017.
- Huang ZD, Zhao YF, Li S, et al. Comparative efficacy and acceptability of pharmaceutical management for adults with post-traumatic stress disorder: a systematic review and meta-analysis. Front Pharmacol. 2020;11:559.
- Arnsten AFT. Stress signalling pathways that impair prefrontal cortex structure and function. Nat Rev Neurosci. 2009;10(6):410–422. PubMed CrossRef
- McEwen BS, Nasca C, Gray JD. Stress effects on neuronal structure: hippocampus, amygdala and prefrontal cortex. Neuropsychopharmacology. 2016;41(1):3–23. [Internet].
- Howes O, McCutcheon R, Stone J. Glutamate and dopamine in schizophrenia: an update for the 21st century. J Psychopharmacol. 2015;29(2):97–115. PubMed CrossRef
- Khouzam HR. Pharmacological and psychoactive agents for treatment resistant posttraumatic stress disorder. Adv Neurol Neurosci. 2021;4(1):83–89.
- Davis AK, Levin AW, Nagib PB, et al. Study protocol of an open-label proof-of concept trial examining the safety and clinical efficacy of psilocybin-assisted therapy for veterans with PTSD. BMJ Open. 2023;13(5):e068884.
- Mitchell JM, Bogenschutz M, Lilienstein A, et al. MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study. Focus. 2023;21(3):315–328.
- Feder A, Parides MK, Murrough JW, et al. Efficacy of intravenous ketamine for treatment of chronic posttraumatic stress disorder: a randomized clinical trial. JAMA Psychiatry. 2014;71(6):681–688. PubMed CrossRef
- O’Haire ME, Guérin NA, Kirkham AC. Animal-assisted intervention for trauma: a systematic literature review. Front Psychol. 2015;6:1121.
- Stephenson KR, Simpson TL, Martinez ME, et al. Changes in mindfulness and posttraumatic stress disorder symptoms among veterans enrolled in mindfulness based stress reduction. J Clin Psychol. 2017;73(3):201–217.
- Office of the Deputy Chief of Staff. A leader’s guide to soldier health and fitness headquarters. Department of the Army [Report]. 2016. Accessed April 14, 2021. https://media.defense.gov/2023/Jul/26/2003268435/-1/-1/1/LEADERS-GUIDETO-SOLDIER-HEALTH-AND-FITNESS.PDF
- Hall-Clark BN, Wright EC, Fina BA, et al. Military culture considerations in prolonged exposure therapy with active-duty military service members. Cognitive Behav Pract. 2019;26(2):335–350.
- Blais RK, Hoerster KD, Malte C, et al. Unique PTSD clusters predict intention to seek mental health care and subsequent utilization in US veterans with PTSD symptoms. J Trauma Stress. 2014;27(2):168–174. PubMed CrossRef
- Hartman A, Schuermann H, Kenney J. US Army soldiers’ trust and confidence in mental health professionals. Prof Couns. 2018;8(3):213–225.
- Hoge CW, Grossman SH, Auchterlonie JL, et al. PTSD treatment for soldiers after combat deployment: low utilization of mental health care and reasons for dropout. Psychiatr Serv. 2014;65(8):997–1004. PubMed CrossRef
- Kim PY, Britt TW, Klocko RP, et al. Stigma, negative attitudes about treatment, and utilization of mental health care among soldiers. Mil Psychol. 2011;23(1):65–81.
- Heyman RE, Slep AMS, Parsons AM, et al. Systematic review of the military career impact of mental health evaluation and treatment. Mil Med. 2022;187(5–6):e598–e618.
- Carvajal C. Poor response to treatment: beyond medication. Dialogues Clin Neurosci. 2022;6(1):93–103.
- Mulvale G, Hurley J. Insurance coverage and the treatment of mental illness: effect on medication and provider use. J Ment Health Pol Econ. 2008;11(4):177–199. PubMed
- VA/DoD Evidence-Based Practice Working Group. VA/DoD Clinical Practice Guidelines. U.S. Department of Veterans Affairs and Department of Defense; 2017.
- Stewart CL, Wrobel TA. Evaluation of the efficacy of pharmacotherapy and psychotherapy in treatment of combat-related post-traumatic stress disorder: a meta-analytic review of outcome studies. Mil Med. 2009;174(5):460–469. PubMed CrossRef
- Liu JW, Nazarov A, Easterbrook B, et al. Four decades of military posttraumatic stress: protocol for a meta-analysis and systematic review of treatment approaches and efficacy. JMIR Res Protoc. 2021;10(10):e33151.
- Borenstein M. Comprehensive meta analysis software. In: Egger M, Higgins JPT, Smith GD, eds. Systematic Reviews in Health Research: Meta Analysis in Context. Wiley;2022:535–548. CrossRef
- RStudio Team. RStudio: Integrated Development for R. RStudio. PBC; 2020. Accessed April 14, 2021. https://www.rstudio.com/.
- Liu JW, Ein N, Gervasio J, et al. Comprehensive meta-analysis of resilience interventions. Clin Psychol Rev. 2020;82:101919. PubMed CrossRef
- Liu JW, Nazarov A, Easterbrook B, et al. The Effectiveness of Pharmacotherapy Versus Psychotherapy for Treating Post-Traumatic Stress Disorder in Military Populations: A Meta-Analysis. PROSPERO; 2021. Accessed April 14, 2021. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021245754.
- Tipton E, Pustejovsky JE, Ahmadi H. A history of meta-regression: technical, conceptual, and practical developments between 1974 and 2018. Res Synth Methods. 2019;10(2):161–179. PubMed CrossRef
- Coventry PA, Meader N, Melton H, et al. Psychological and pharmacological interventions for posttraumatic stress disorder and comorbid mental health problems following complex traumatic events: systematic review and component network meta-analysis. PLoS Med. 2020;17(8):e1003262. PubMed CrossRef
- Guidi J, Fava GA. Conceptual and clinical innovations of well-being therapy. Int J Cogn Ther. 2021;14(1):196–208.
- Puetz TW, Youngstedt SD, Herring MP. Effects of pharmacotherapy on symptoms of post-traumatic stress disorder: a meta-analysis. J Clin Psychiatry. 2015;76(9):1234–1242.
- Sonis J, Cook JM. Medication versus trauma-focused psychotherapy for adults with posttraumatic stress disorder: a systematic review and meta-analysis. Psychiatry Res. 2019;282:112637. PubMed CrossRef
Please sign in or purchase this PDF for $40.
Save
Share
Cite
