Do early interventions prevent PTSD? A systematic review and meta-analysis of the safety and efficacy of early interventions after sexual assault.

The short version

This systematic review and meta-analysis explored whether psychological help offered within 3 months of a sexual assault can reduce or prevent posttraumatic stress disorder (PTSD), a condition in which distressing memories, avoidance and heightened alertness persist after trauma. The authors searched six databases for studies from 1980 to April 2018, and excluded psychological debriefing because earlier work found it harmful. They report that this narrow question had not been reviewed before. Seven studies with 350 participants met the criteria and tested five different early interventions, a small evidence base that the authors describe as diverse in design and timing. The included studies were mostly of women in high-income countries, with average ages of 22 to 34, recruited through hospitals, forensic examinations or counselling centres. Interventions ranged from a single 9- or 17-minute educational video to a 113-minute EMDR session (eye movement desensitization and reprocessing, in which a person recalls a trauma while following guided eye movements), a modified prolonged exposure session (structured, repeated recalling of the trauma), cognitive restructuring with relaxation, and six weeks of cognitive processing therapy. Two authors independently screened studies and rated risk of bias; four studies compared with standard care were pooled. Pooling four studies, early intervention did not clearly reduce PTSD severity at 1 to 6 weeks (g = -0.28, 95% CI -0.57 to 0.02; g is a standardized effect size, where negative favors intervention), though all four leaned that way. At 2 to 12 months, a small effect just reached significance (g = -0.23, 95% CI -0.46 to 0.00), with no measured heterogeneity. Two studies that compared PTSD diagnoses found no difference between groups. Safety data were thin: only two studies reported adverse events, and none used an active strategy to detect harm, though author contact turned up no serious events. All seven studies were judged at high risk of bias, and true randomization occurred in only two of the five studies that compared treatment groups, which the authors link to a high risk of selection bias. The authors suggest that early interventions may lead to lasting reductions in PTSD severity after sexual assault, but state that definite conclusions about safety, efficacy and PTSD prevention are impossible with so few, heterogeneous, high-risk-of-bias studies. They also note that the studies used older PTSD definitions from DSM-III-R and DSM-IV. They call for trials that actively track harm, report PTSD diagnoses as well as symptom scores, compare early with later treatment, and consider cost and access for survivors.

Key findings

• This review pooled seven studies with 350 people who received psychological help within three months of a sexual assault, testing five different approaches including a video, EMDR (a therapy using guided eye movements while recalling a trauma), and prolonged exposure (structured recalling of the trauma).
• Combined results showed no clear reduction in post-traumatic stress symptoms one to six weeks later, but a small reduction at two to twelve months (an effect size of -0.23, where negative favors early help), which only just reached statistical significance.
• Only two of the seven studies reported on safety, and none set out an active plan to look for harm, although the authors found no evidence that early help was unsafe.
• All seven studies were rated at high risk of bias, with true randomization in only two of the five studies that compared groups, so the authors state that no firm conclusions about safety or efficacy can yet be drawn.

Common questions