Comparative Effectiveness Review Number 235 R Pharmacologic and Nonpharmacologic Treatments for Posttraumatic Stress Disorder: An Update of the PTSD-Repository Evidence Base Comparative Effectiveness Review Number 235 Pharmacologic and Nonpharmacologic Treatments for Posttraumatic Stress Disorder: An Update of the PTSD-Repository Evidence Base Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 5600 Fishers Lane Rockville, MD 20857 www.ahrq.gov Contract No. 290-2015-00009-I Prepared by: Pacific Northwest Evidence-based Practice Center Portland, OR Investigators: Maya E. O’Neil, Ph.D., M.C.R. Tamara P. Cheney, M.D. Frances C. Hsu, M.S. Kathleen F. Carlson, Ph.D., M.S. Erica L. Hart, M.S.T. Rebecca S. Holmes, M.D., M.S. Katrina M. Murphy, B.S. Elaine Graham, M.L.S. David C. Cameron, M.P.H. Julie Kahler, Ph.D. Meaghan Lewis, Ph.D. Josh Kaplan, Ph.D. Marian S. McDonagh, Pharm.D. AHRQ Publication No. 20(21)-EHC029 November 2020 This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00009-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report. The information in this report is intended to help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of healthcare services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients. This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders. AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied. AHRQ appreciates appropriate acknowledgment and citation of its work. Suggested language for acknowledgment: This work was based on an evidence report, Pharmacologic and Nonpharmacologic Treatments for Posttraumatic Stress Disorder: An Update of the PTSD- Repository Evidence Base, by the Evidence-based Practice Center Program at the Agency for Healthcare Research and Quality (AHRQ). Suggested citation: O’Neil ME, Cheney TP, Hsu FC, Carlson KF, Hart EL, Holmes RS, Murphy KM, Graham E, Cameron DC, Kahler J, Lewis M, Kaplan J, McDonagh MS. Pharmacologic and Nonpharmacologic Treatments for Posttraumatic Stress Disorder: An Update of the PTSD-Repository Evidence Base. Comparative Effectiveness Review No. 235. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 20(21)-EHC029. Rockville, MD: Agency for Healthcare Research and Quality; November 2020. DOI: https://doi.org/10.23970/AHRQEPCCER235. Posted final reports are located on the Effective Health Care Program search page. ii Preface The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based Practice Centers (EPCs), sponsors the development of evidence reports and technology assessments to assist public- and private-sector organizations in their efforts to improve the quality of healthcare in the United States. The U.S. Department of Veterans Affairs requested this report from the EPC Program at AHRQ. The reports and assessments provide organizations with comprehensive, evidence-based information on common, costly medical conditions, and new healthcare technologies and strategies. This evidence report provides an overview of key issues related to the interventions included—for example, current indications, relevant patient populations and subgroups of interest, outcomes measured, and contextual factors that may affect decisions regarding the intervention. The report includes data abstracted from published randomized controlled trials on interventions for posttraumatic stress disorder. These data were adapted to support the development of a publicly available repository by the National Center for Posttraumatic Stress Disorder (NCPTSD). AHRQ expects that the EPC evidence reports and technology assessments, when appropriate, will be helpful to health plans, providers, purchasers, government programs, and the healthcare system as a whole. Transparency and stakeholder input are essential to the Effective Health Care Program. Please visit the website (www.effectivehealthcare.ahrq.gov) to see draft research questions and reports or to join an email list to learn about new program products and opportunities for input. If you have comments on this systematic review, they may be sent by mail to the Task Order Officer named below at: Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, MD 20857, or by email to [email protected]. Gopal Khanna, M.B.A Arlene S. Bierman, M.D., M.S. Director Director Agency for Healthcare Research and Quality Center for Evidence and Practice Improvement Agency for Healthcare Research and Quality Stephanie Chang, M.D., M.P.H. Kim Wittenberg, M.A. Director Task Order Officer Evidence-based Practice Center Program Center for Evidence and Practice Center for Evidence and Practice Improvement Improvement Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality Jessica L. Hamblen, Ph.D. Sonya B. Norman, Ph.D. Deputy for Education, National Center for PTSD Consultation Program Director Posttraumatic Stress Disorder National Center for Posttraumatic Stress Department of Veterans Affairs Disorder Department of Veterans Affairs iii Acknowledgments The authors gratefully acknowledge the following individuals for their contributions to this project: Tracy Dana, M.L.S., and Leah Williams, B.S. Technical Expert Panel In designing the study questions and methodology at the outset of this report, the EPC consulted several technical and content experts. Broad expertise and perspectives were sought. Divergent and conflicted opinions are common and perceived as healthy scientific discourse that results in a thoughtful, relevant systematic review. Therefore, in the end, study questions, design, methodologic approaches, and/or conclusions do not necessarily represent the views of individual technical and content experts. Technical Experts must disclose any financial conflicts of interest greater than $5,000 and any other relevant business or professional conflicts of interest. Because of their unique clinical or content expertise, individuals with potential conflicts may be retained. The TOO and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified. The list of Technical Experts who provided input to this report follows: Content Technical Expert Panel Jonathan I. Bisson, D.M., F.R.C.Psych.* Professor, Division of Psychological Medicine and Clinical Neurosciences Cardiff University Cardiff, Wales Susan Borja, Ph.D.* Program Chief National Institute of Mental Health Bethesda, MD Lori Davis, M.D. Professor, Psychiatry and Behavioral Neurobiology University of Alabama Tuscaloosa VA Medical Center Tuscaloosa, AL Lauren Denneson, M.S., Ph.D.* Core Investigator, Center to Improve Veteran Involvement in Care VA Portland Health Care System Associate Professor, Psychiatry Oregon Health & Science University Portland, OR iv Tara Galovski, Ph.D.* Director, Women’s Health Sciences Division National Center for PTSD Associate Professor, Psychiatry Boston University School of Medicine VA Boston Healthcare System Boston, MA Denise Hien, Ph.D., A.B.P.P.* Director, Center of Alcohol & Substance Use Studies Rutgers University Piscataway, NJ David Kearney, M.D. Professor, Medicine and Gastroenterology University of Washington VA Puget Sound Health Care System Seattle, WA Ariel Lang, Ph.D., M.P.H.* Professor in Residence, Psychiatry University of California San Diego VA Center of Excellence for Stress and Mental Health La Jolla, CA Tracy Simpson, Ph.D.* Professor, Psychiatry and Behavioral Science University of Washington VA Puget Sound Health Care System Seattle, WA Risk of Bias Technical Expert Panel Nancy Berkman, Ph.D.* Fellow, Health Services Research RTI International Research Triangle Park, NC M. Hassan Murad, M.D.* Director Mayo Clinic Evidence-based Practice Center Rochester, MN Neil Roberts, M.D. Senior Research Fellow, Psychological Medicine and Clinical Neurosciences Cardiff University v Cardiff, Wales Todd Semla, Pharm.D.* Clinical Associate Professor, Psychiatry and Behavioral Sciences