Comparative efficacy and acceptability of pharmacological treatments for post-traumatic stress disorder in adults: a network meta-analysis

• Published in: Psychological medicine Vol. 48; no. 12; pp. 1975 - 1984
• Main Authors: Cipriani, Andrea, Williams, Taryn, Nikolakopoulou, Adriani, Salanti, Georgia, Chaimani, Anna, Ipser, Jonathan, Cowen, Phil J., Geddes, John R., Stein, Dan J.
• Format: Journal Article
• Language: English
• Published: Cambridge, UK Cambridge University Press 01.09.2018
• Subjects: Adult; Antidepressants; Bias; Desipramine; Dropping out; Drug dosages; Drug therapy; Efficacy; Fluoxetine; Humans; Meta-analysis; Middle Aged; Network Meta-Analysis; Neurotransmitter Agents - pharmacology; Oral therapy; Original Articles; Outcome Assessment (Health Care) - statistics & numerical data; Paroxetine; Patient Acceptance of Health Care - statistics & numerical data; Pharmaceutical industry; Post traumatic stress disorder; Psychotropic drugs; Random effects; Ratings & rankings; Registries - statistics & numerical data; Risperidone; School dropouts; Sertraline; Stress Disorders, Post-Traumatic - drug therapy; Systematic review; Treatment methods; Uncertainty; Valproic acid; Venlafaxine; systematic review; Network meta-analysis; post-traumatic stress disorder
• ISSN: 0033-2917; 1469-8978
• DOI: 10.1017/S003329171700349X

Guidelines about post-traumatic stress disorder (PTSD) recommend broad categories of drugs, but uncertainty remains about what pharmacological treatment to select among all available compounds. Cochrane Central Register of Controlled Trials register, MEDLINE, PsycINFO, National PTSD Center Pilots database, PubMed, trial registries, and databases of pharmaceutical companies were searched until February 2016 for double-blind randomised trials comparing any pharmacological intervention or placebo as oral therapy in adults with PTSD. Initially, we performed standard pairwise meta-analyses using a random effects model. We then carried out a network meta-analysis. The main outcome measures were mean change on a standardised scale and all-cause dropout rate. Acute treatment was defined as 8-week follow up. Desipramine, fluoxetine, paroxetine, phenelzine, risperidone, sertraline, and venlafaxine were more effective than placebo; phenelzine was better than many other active treatments and was the only drug, which was significantly better than placebo in terms of dropouts (odds ratio 7.50, 95% CI 1.72-32.80). Mirtazapine yielded a relatively high rank for efficacy, but the respective value for acceptability was not among the best treatments. Divalproex had overall the worst ranking. The efficacy and acceptability hierarchies generated by our study were robust against many sources of bias. The differences between drugs and placebo were small, with the only exception of phenelzine. Considering the small amount of available data, these results are probably not robust enough to suggest phenelzine as a drug of choice. However, findings from this review reinforce the idea that phenelzine should be prioritised in future trials in PTSD.