Psychological or social interventions for persons with simultaneous psychosis and PTSD

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SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

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Published: Report no: ut202507 Registration no: SBU 2024/958

Question

What systematic reviews have been published regarding the effects of psychological or social interventions for persons with simultaneous psychosis and PTSD?

PICO

  • Population: Persons diagnosed with psychosis and PTSD.
  • Intervention: Psychological interventions, social and supportive interventions, and interventions targeting friends and relatives.
  • Comparison: Other active intervention or treatment as usual.
  • Outcome: Trauma symptoms, symptoms of psychosis, remission of diagnos, health care consumption, quality of life, social relations, return to work.

Method

A systematic literature search was performed using the following databases: Medline, Scopus, and PsycInfo.
Two authors independently assessed the abstracts of all identified studies.
Risk of bias in relevant systematic reviews was assessed using an assessment tool based on AMSTAR.

Identified literature

Two relevant systematic reviews with moderate risk of bias were identified [1, 2]. The results and conclusions are presented in Table 1. In one relevant systematic review, the risk of bias was considered to be high, therefore the results and conclusions are not reported [3].

Table 1 Systematic reviews with moderate risk of bias.
* = same studies in both systematic reviews.

BD-II = Beck Depression Inventory 2;CAPS= Clinician-Administered PTSD Scale; MD = Mean difference;PSYRATS = Psychotic Symptom Rating Scales; PTCI = Posttraumatic Cognitions Inventory; RR = Risk ratio; SMI = Severe Mental Illness; TF = Trauma-focused; TFPI = Trauma-focused psychological interventions
Included studies Population, Intervention, Control Outcome and Results
Sin et al, 2017 [2]
Psychological interventions for post-traumatic stress disorder (PTSD) in people with severe mental illness
4 RCT studies
(n=525) 
Relevant studies:
3 RCT studies
(n=324) 

Setting:
England:
1 study*
Netherlands:
1 study*
USA:
1 study		 Population:
Patients with diagnosis of schizophrenia or schizoaffective disorder and current diagnosis of PTSD 

Intervention:
Trauma-focused Cognitive Behavioural Therapy
(CBT for PTSD or Prolonged Exposure) 

Control:
Treatment as usual or wait-list		 PTSD symptom severity (clinician-rated, CAPS)
Short term [<6 months]
(2 studies, n=77):
No difference (p=0.50)
MD: –7.44
(95% CI, –29.15 to 14.27) 

Medium term [7–12 months]
(3 studies, n=82):
No difference (p=0.62)
MD: –3.92
(95% CI, –19.25 to 11.40) 

PTSD symptom severity (self-reported, Trauma-related cognition, PTCI)
Short term [<6 months]
(3 studies, n=73):
No difference (p=0.07)
MD: –5.45
(95% CI, –33.61 to 22.70) 

Medium term [7–12 months]
(3 studies, n=82):
Favouring TF-CBT (p=0.04)
MD: –15.25
(95% CI, –29.48 to –1.02) 

PTSD symptom severity (Remission from PTSD, CAPS)
Short term [<6 months]
(2 studies, n=61):
Favouring TF-CBT (p=0.01)
RR: 1.99
(95% CI, 1.20 to 3.30) 

Medium term [7–12 months]
(2 studies, n=60):
No difference (p=0.44)
RR: 1.44
(95% CI, 0.57 to 3.63) 

Depressive symptoms (BD-II)
Short term [<6 months]
(2 studies, n=27):
No difference (p=0.72)
MD: 1.31(95% CI, –5.81 to 8.44)

Medium term [7–12 months]
(2 studies, n=27):
No difference (p=0.36)
MD: 3.26
(95% CI, –3.66 to 10.18) 
Authors' conclusion:
“Although this review provides some preliminary albeit low quality evidence on the feasibility and safety of TF-CBT and EMDR, targeting service users with SMI and PTSD, the results of treatment effect on PTSD, psychotic and other symptoms are largely equivocal. Due to a small number of studies of the effects of TFPIs for this co-morbid population, there were limited data, often from only one study, available for the outcomes under investigation for each modality of therapy.”
Brand et al, 2018 [1]
Do trauma-focussed psychological interventions have an effect on psychotic symptoms? A systematic review and meta-analysis
25 studies 

Relevant studies:
2 RCT studies
(n=216) 

Setting:
England: 1 study*
Netherlands: 1 study*		 Population:
Patients with diagnosis of schizophrenia or schizoaffective disorder and current diagnosis of PTSD 

Intervention:
Trauma-focused Cognitive Behavioural Therapy (CBT for PTSD or Prolonged Exposure) 

Control:
Treatment as usualor wait-list		 Delusions (PSYRATS)
Post-treatment:
No difference (p=0.14)
Hedge’s g: 0.37
(95% CI, –0.12 to 0.87) 

Follow-up [6 months]:
Favouring intervention (p<0.01)
Hedge’s g: 0.38
(95% CI, 0.10 to 0.67) 

Hallucinations (PSYRATS)
Post-treatment:
No difference (p=0.69)
Hedge’s g: 0.14
(95% CI, –0.55 to 0.82) 

Follow-up [6 months]:
No difference (p=0.72)
Hedge’s g: –0.06
(95% CI, –0.42 to 0.29)
Authors' conclusion:
“In considering delusions and hallucinations separately, small effects for delusions were found at both post-treatment and follow-up, but these only reached significance at follow-up, whereas effects for hallucinations were negligible and non-significant at both time points.”

References

  1. Brand RM, McEnery C, Rossell S, Bendall S, Thomas N. Do trauma-focussed psychological interventions have an effect on psychotic symptoms? A systematic review and meta-analysis. Schizophr Res. 2018;195:13-22. Available from: https://doi.org/10.1016/j.schres.2017.08.037
  2. Sin J, Spain D, Furuta M, Murrells T, Norman I. Psychological interventions for post-traumatic stress disorder (PTSD) in people with severe mental illness. Cochrane Database Syst Rev. 2017;1(1):CD011464. Available from: https://doi.org/10.1002/14651858.CD011464.pub2
  3. Sin J, Spain D. Psychological interventions for trauma in individuals who have psychosis: A systematic review and meta-analysis. Psychosis. 2016;9(1):67-81. Available from: https://doi.org/10.1080/17522439.2016.1167946

Search strategy

Medline via OvidSP 04 Feb 25

Title: PTSD och Psykos
/ = Term from the MeSH controlled vocabulary; .sh = Term from the MeSH controlled vocabulary;exp = Term from MeSH including terms found below this term in the MeSH hierarchy; .ti,ab = Title or abstract; .tw = Title or abstract; .kf = Keywords; .kw = Keywords, exact; .bt = Book title. NLM Bookshelf; .pt = Publication type; .ja = Journal abbreviation; .af = All fields;adjn = Adjacent. Proximity operator retrieving adjacent words, adj3 retrieves records with search terms within two terms from each other; * or $ = Truncation; “ “ = Citation Marks; searches for an exact phrase
Search terms Items found
PTSD:
1. Stress Disorders, Post-Traumatic/ 44 908
2. (“post-traumatic stress” or “posttraumatic stress” or PTSD or PTS).ab,ti,kf,bt. 71 157
3. (“complex post-traumatic stress” or “complex posttraumatic stress” or ”CPTSD” or “C-PTSD” or “complex ptsd” or ”complex pts” or ”DESNOS” or ”EPCACE” or (complex adj3 (trauma* or stress)) or (extreme* adj3 (trauma* or stress*)) or (catastrophic* adj3 (experience* or event*)) or ((trauma* or stress*) adj3 disorder*)).ab,ti,kf,bt. 68 348
4. Or/1-3 103 842
Psychosis:
5. Exp Schizophrenia Spectrum or Other Psychotic Disorders/ 168 834
6. Exp Psychotic Disorders/ 61 046
7. (psychos* or psychotic* or schizo* or hallucinat* or delusion* or paranoi* or paraphreni*).ab,ti,kf,bt. 404 182
8. Or/5-7 434 785
Study types: systematic reviews and meta-analysis
9. ((Systematic Review/ or Meta-Analysis/ or Cochrane Database Syst Rev.ja. or ((systematic adj4 review) or "meta analys*" or metaanalys*).ti,bt,ab.) not (editorial/ or letter/ or case reports/)) 525 613
Combined sets:
10. 4 AND 8 AND 9 626
Final result
11. 4 AND 8 AND 9 626

Scopus via scopus.com 04 Feb 25

Title: PTSD och Psykos
TITLE-ABS-KEY;= Title, abstract or keywords (including indexed keywords and author keywords); ALL = All fields; W/n = Within. Proximity operator retrieving terms within n words from each other; PRE/n = Precedes by. Proximity operator, the first term in the search must precede the second by n words; LIMIT-TO (X);= Includes only results of specified type, e.g., publication type or time range; DOCTYPE = Publication type; “re” = review; “le” = letter; “ed” = editorial; “ch” = book chapter; “cp” = conference proceedings; * = Truncation; “ “= Citation Marks; searches for an exact phrase
Search terms Items found
PTSD:
1. TITLE-ABS-KEY (PTSD OR PTS OR (trauma* W/3 stress*) OR (stress* OR trauma* W/3 disorder*)) 168 732
2. TITLE-ABS-KEY (“complex post-traumatic stress” OR “complex posttraumatic stress” OR CPTSD OR C-PTSD OR DESNOS OR EPCACE OR ”complex PTSD” OR ”complex PTS” OR (complex* W/4 (trauma* OR stress*)) OR (catastrophic* W/3 (experience* OR event*)) OR (extreme* W/3 (stress* OR trauma*))) 52 352
3. 1 OR 2 217 378
Psychosis:
4. TITLE-ABS-KEY (psychos* OR psychotic* or schizo* or hallucinat* or delusion* or paranoi* OR paraphreni*) 708 372
Study types: systematic reviews and meta-analysis
5. TITLE-ABS-KEY ( ( systematic W/2 review ) OR "meta analy*" OR metaanaly* ) AND (EXCLUDE (DOCTYPE, “le”) OR EXCLUDE (DOCTYPE, “ed”) OR EXCLUDE (DOCTYPE, “ch”) OR EXCLUDE (DOCTYPE, “cp”)) 778 117
Combined sets:
6. 3 AND 4 AND 5 1684
Final result
7. 3 AND 4 AND 5 1684

PSYCINFO via EBSCO 04 Feb 25

Title: PTSD och Psykos
TI = Title; AB = Abstract;SU = Keyword, exact or part (including all other fields for indexed and author keywords); DE = Exact keyword; TX = All text; MR = Methodology; Nn = Near. Proximity operator retrieving terms within words from each other; * = Truncation; “ “= Citation Marks; searches for an exact phrase
Search terms Items found
PTSD:
1. DE “Posttraumatic Stress Disorder” 43 712
2. DE “Complex PTSD” 819
3. DE “Emotional Trauma” 16 653
4. DE “Traumatic Experiences” 1598
5. DE “Trauma Treatment” 709
6. TI(post-traumatic* or posttraumatic* or PTSD or PTS or ((stress* or trauma*) N3 disorder*)) 34 089
7. AB(post-traumatic* or posttraumatic* or PTSD or PTS or ((stress* or trauma*) N3 disorder*)) 74 561
8. SU(post-traumatic* or posttraumatic* or PTSD or PTS or ((stress* or trauma*) N3 disorder*)) 59 907
9. TI(“complex posttraumatic stress” or “complex post-traumatic stress” or “complex ptsd” or “complex pts” or CPTSD or C-PTSD or DESNOS or EPCACE or (catastrophic N3 (experience* or event*)) or (extreme* N3 (trauma* or stress*)) 4252
10. AB(“complex posttraumatic stress” or “complex post-traumatic stress” or “complex ptsd” or “complex pts” or CPTSD or C-PTSD or DESNOS or EPCACE or (catastrophic N3 (experience* or event*)) or (extreme* N3 (trauma* or stress*)) 4328
11. SU(“complex posttraumatic stress” or “complex post-traumatic stress” or “complex ptsd” or “complex pts” or CPTSD or C-PTSD or DESNOS or EPCACE or (catastrophic N3 (experience* or event*)) or (extreme* N3 (trauma* or stress*)) 4257
12. Or/1-11 97 662
Psychosis:
13. DE “Schizophrenia” 110 861
14. DE “Paranoid Schizophrenia” 2088
15. DE “Process Schizophrenia” 70
16. DE “Schizoaffective Disorder” 3428
17. DE “Schizophrenia (Disorganized Type)” 190
18. DE “Undifferentiated Schizophrenia” 117
19. DE “Psychosis” 35 771
20. DE “Affective Psychosis” 606
21. DE “Chronic Psychosis” 260
22. DE “Delusional Disorder” 35
23. DE “Hallucinosis” 160
24. DE “Paranoid Psychosis” 1336
25. DE “Reactive Psychosis” 287
26. TI(psychotic or psychos* or schizophreni* or delusion* or hallucin* or paraphreni* or affective psycho*) 144 813
27. AB(psychotic or psychos* or schizophreni* or delusion* or hallucin* or paraphreni* or affective psycho*) 309 361
28. SU(psychotic or psychos* or schizophreni* or delusion* or hallucin* or paraphreni* or affective psycho*) 297 928
29. Or/13-28 560 119
Study types: systematic reviews and meta-analysis
30. TI((systematic n3 review) OR "meta analys*" OR metaanalys*) OR AB((systematic n3 review) OR "meta analys*" OR metaanalys*) OR SU((systematic n3 review) OR "meta analys*" OR metaanalys*) OR (MR "Systematic Review" OR MR "meta analysis") 109 296
Combined sets:
31. 12 AND 29 AND 30 669
Final result
32. 12 AND 29 AND 30 669
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