Expressive Writing Interventions in Cancer Patients a Systematic Review
Introduction
After the experience of a traumatic event negative health-related symptoms can be observed in many developed trauma survivors. The range of negative symptoms typically includes re-experiencing the trauma, hyperarousal and avoidance of trauma-associated stimuli – the three cadre symptom clusters of the posttraumatic stress disorder diagnosis – even so, alterations in mood and cognition occur besides (American Psychiatric Clan, 2013). Most 10% to 20% of trauma survivors evidence all symptoms of a total-blown posttraumatic stress disorder (PTSD; Norris & Slone, Reference Norris, Slone, Friedman, Keane and Resick2007), and around eight% of adults meet PTSD criteria at least one time in their life (de Vries & Olff, Reference de Vries and Olff2009; Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, Reference Kessler, Petukhova, Sampson, Zaslavsky and Wittchen2012). All the same, the diagnosis of PTSD is not very distinct, with many possible manifestations and combinations of symptoms (Galatzer-Levy & Bryant, Reference Galatzer-Levy and Bryant2013). In addition, partial PTSD is as well associated with considerable impairments (Marshall et al., Reference Marshall, Olfson, Hellman, Blanco, Guardino and Struening2001), and with similar health-seeking behaviour every bit observed among individuals who fulfil diagnostic criteria for PTSD (Stein, Walker, Hazen, & Forde, Reference Stein, Walker, Hazen and Forde1997). PTSD symptoms have a high risk for chronicity, comorbid medical and psychiatric symptoms, and suicide (Frayne et al., Reference Frayne, Seaver, Loveland, Christiansen, Spiro, Parker and Skinner2004; Kessler et al., Reference Kessler, Berglund, Demler, Jin, Merikangas and Walters2005; Kessler, Sonnega, Bromet, Hughes, & Nelson, Reference Kessler, Sonnega, Bromet, Hughes and Nelson1995; Krysinska & Lester, Reference Krysinska and Lester2010; Pietrzak, Goldstein, Southwick, & Grant, Reference Pietrzak, Goldstein, Southwick and Grant2011, Reference Pietrzak, Goldstein, Southwick and Grant2012; Wittchen et al., Reference Wittchen, Jacobi, Rehm, Gustavsson, Svensson, Jonsson and Steinhausen2011). Further, PTSD symptoms often lead to social and occupational impairment, and are associated with substantial economic and societal costs (Kessler, Reference Kessler2000). National handling guidelines suggest several efficacious treatments for PTSD (Forbes et al., Reference Forbes, Creamer, Bisson, Cohen, Crow, Foa and Ursano2010), including a variety of trauma-focused psychotherapeutic treatment approaches (American Psychological Association, 2017; Foa, Keane, Friedman, & Cohen, Reference Foa, Keane, Friedman and Cohen2009; Forbes et al., Reference Forbes, Creamer, Phelps, Bryant, McFarlane, Devilly and Newton2007; Constitute of Medicine, 2008; National Institute for Wellness and Care Excellence, 2005; World Health Organisation, 2013), but likewise pharmacological treatments (American Psychological Association, 2017; Foa et al., Reference Foa, Keane, Friedman and Cohen2009). Notwithstanding, many patients with PTSD do not receive adequate treatment for their symptoms (Lewis et al., Reference Lewis, Arseneault, Caspi, Fisher, Matthews, Moffitt and Danese2019; Liebschutz et al., Reference Liebschutz, Saitz, Brower, Keane, Lloyd-Travaglini, Averbuch and Samet2007; Rodriguez et al., Reference Rodriguez, Weisberg, Pagano, Machan, Culpepper and Keller2003).
In 1986, writing about one's own trauma experience was proposed equally potentially beneficial handling for trauma survivors by Pennebaker and Beall (Reference Pennebaker and Beall1986). Expressive writing originally consisted of iv writing sessions of 15 minutes elapsing and did not involve additional contact with a mental wellness professional. Initially, promising results have been demonstrated for expressive writing treatment in reducing symptom severity and increasing well-being (Smyth, Reference Smyth1998). Notwithstanding, benefits in subsequent meta-analyses were mostly small to moderate reflecting considerable variations of handling effects across meta-analyses (Frattaroli, Reference Frattaroli2006; Frisina, Borod, & Lepore, Reference Frisina, Borod and Lepore2004; Mogk, Otte, Reinhold-Hurley, & Kröner-Herwig, Reference Mogk, Otte, Reinhold-Hurley and Kröner-Herwig2006; Smyth & Pennebaker, Reference Smyth and Pennebaker2008). These findings motivated adaptions of the original paradigm in gild to increment the initially observed beneficial treatment effects of writing treatments (Smyth & Pennebaker, Reference Smyth and Pennebaker2008). Such adaptions, for example, included the addition of interactions with a therapist or the provision of more than detailed and guided writing instructions. Importantly, the main component of the treatment remained the writing itself and a number of mechanisms have been described to explain the observed treatment benefits (including improved cocky-regulation, cognitive processing of the trauma memory, and restoring perceptions of control; Andersson & Conley, Reference Andersson and Conley2008; Frattaroli, Reference Frattaroli2006; Smyth & Pennebaker, Reference Smyth and Pennebaker2008). Likewise the assumed beneficial health furnishings, the parsimony of writing treatments, as well equally the huge potential to close gaps in the provision of PTSD treatment through remote (e.1000. online) commitment may have contributed to the treatment's continuing popularity over the concluding three decades. Several meta-analyses have been conducted over the terminal 20 years that showed small to moderately sized beneficial furnishings of the original expressive writing assignments in improving PTSD symptoms (Frattaroli, Reference Frattaroli2006; Frisina et al., Reference Frisina, Borod and Lepore2004; Mogk et al., Reference Mogk, Otte, Reinhold-Hurley and Kröner-Herwig2006; Smyth, Reference Smyth1998; Smyth & Pennebaker, Reference Smyth and Pennebaker2008). More recent meta-analyses focused on novel developments in writing treatments and did not include studies using the original writing paradigm (Kuester, Niemeyer, & Knaevelsrud, Reference Kuester, Niemeyer and Knaevelsrud2016; van Emmerik, Reijntjes, & Kamphuis, Reference van Emmerik, Reijntjes and Kamphuis2013).
While early randomized clinical trials (RCTs) evaluating the effects of writing treatments primarily used neutral writing assignments as command groups (e.grand. writing about daily activities), more contempo RCTs also incorporated passive comparators (i.eastward. waiting list command), and psychotherapeutic PTSD treatments. Today's plethora of available RCTs creates the opportunity to brand multiple comparisons between the original and adjusted writing treatments, psychotherapeutic PTSD treatments, equally well as active and passive control groups in RCTs of writing treatments. The complex pattern of evidence from these differently controlled RCTs complicates the integration of bachelor research findings using conventional pairwise meta-analytic approaches and calls for a network meta-analytic summary of available RCTs.
We conducted a systematic review and network meta-analysis including studies with full and partial PTSD as well as studies which included participants who had been exposed to trauma and suffered from PTSD symptoms. We included all available direct comparisons betwixt an expressive writing treatment as stand-alone treatment (i.eastward. non as role of a complex treatment packet) that was compared with a psychotherapeutic PTSD handling, with an agile writing control, or with a passive waiting-list control. We distinguished betwixt original and enhanced writing treatments and summarized the bachelor evidence in the short- and long-term.
Methods
This written report was conducted in accord with the PRISMA-NMA statement (Hutton et al., Reference Hutton, Salanti, Caldwell, Chaimani, Schmid, Cameron and Jansen2015; Moher, Liberati, Tetzlaff, Altmann, & Group, Reference Moher, Liberati, Tetzlaff, Altmann and Group2009), and was registered on PROSPERO (number: CRD 42018094075; Gerger, Gaab, & Werner, Reference Gerger, Gaab and Werner2018).
Identification of studies
We searched EMBASE, Medline, PsycINFO, and Cochrane Controlled Trials Register using fundamental words and text words related to writing treatments, trauma experience and RCTs (see eAppendix 1). In improver, one researcher (CW) searched through the reference lists of relevant systematic reviews, and meta-analyses (Frattaroli, Reference Frattaroli2006; Frisina et al., Reference Frisina, Borod and Lepore2004; Kuester et al., Reference Kuester, Niemeyer and Knaevelsrud2016; Mogk et al., Reference Mogk, Otte, Reinhold-Hurley and Kröner-Herwig2006; Smyth, Reference Smyth1998; van Emmerik et al., Reference van Emmerik, Reijntjes and Kamphuis2013) for potentially relevant trials. The initial literature search was conducted between 8 June 2016 and 15 November 2016. The final update of the database search was conducted on vi September 2020. Written report inclusion was finished on 5 October 2020. Two reviewers (CW and HG) independently screened the full texts of potentially relevant publications using a structured manual. Disagreements were resolved past consensus.
Selection criteria
We included RCTs that applied at least one trauma-focused writing handling, which aimed at reducing PTSD symptoms, and which was not part of a complex treatment package. We allowed whatever delivery method (e.g. paper and pencil or electronic or net-based ), as long as it was a purely written intervention and not mixed with any other intervention like verbal cognitive behavioural therapy. RCTs were included even when the trauma-focused writing handling was not the primary focus of the experimental investigation but served as a control status for psychotherapy. We included comparisons betwixt trauma-focused expressive writing treatments with PTSD psychotherapies, neutral writing and waiting-list control groups.
We defined trauma-focused writing as a writing handling that targeted the traumatic event the participant had experienced. We classified expressive writing treatments as 1st those that referred to the original paradigm by Pennebaker and Beall (Reference Pennebaker and Beall1986), and iind as enhanced writing interventions those that included additional elements assumed to increase their efficacy (i.eastward. therapist contact exceeding the initial writing instruction, or more elaborated and directive instructions for each private writing session). Writing treatments were classified as expressive writing (EW) if authors either explicitly referred to the original paradigm by Pennebaker and Beall (Reference Pennebaker and Beall1986), or writing treatments were similarly structured equally the original writing paradigm (e.chiliad. three3–iv sessions of fifteen–thirty min duration). Importantly, to be considered EW no therapist involvement was immune. As well, no individualized instructions for each writing session were allowed. Writing treatments were classified as enhanced writing (EW+) if the treatment description 1st did not explicitly refer to the original Pennebaker writing paradigm and if iind writing treatments included additional elements assumed to increase their efficacy: the treatments included either the presence of a therapist during writing sessions, or any therapist feedback. In many cases experimental manipulation of the writing content was used (e.g. more directive writing instructions which changed for each writing session). Enhanced writing treatments typically also used more or longer writing sessions compared with the original epitome. However, the use of longer sessions alone was non sufficient for a writing treatment to classify equally enhanced writing. Studies that used only experimental manipulations of formal aspects of the writing task (e.g. writing in the first-person v. writing in the 3rd-person; Andersson & Conley, Reference Andersson and Conley2013; Kenardy & Tan, Reference Kenardy and Tan2006) but which had no additional comparator were not included in the analyses. Neutral command writing was defined every bit a writing task that did not focus on a traumatic upshot (e.k. writing about daily tasks). We included RCTs with adults (i.eastward. hateful age of the study sample was 18 or higher up). Participants needed to take experienced at least one traumatic outcome co-ordinate to the Diagnostic and Statistical Manual of Mental Disorders fifth edition PTSD benchmark A (DSM-five; American Psychiatric Association, 2013), and they needed to study the occurrence of either total or partial PTSD, or the presence of PTSD symptoms in the aftermath of trauma experience (encounter eAppendix ii for a more detailed description). We excluded studies on expressive writing with samples that did not report the presence of PTSD symptoms (e.yard. Burton & King, Reference Burton and King2004; Pennebaker & Beall, Reference Pennebaker and Beall1986; Ramirez & Beilock, Reference Ramirez and Beilock2011; Tondorf et al., Reference Tondorf, Kaufmann, Degel, Locher, Birkhäuer, Gerger and Gaab2017). We had no language restrictions and we did not crave studies to be double-blind for inclusion, as a blinding of therapists and participants is non possible in psychotherapy research.
Outcomes
Our main outcome was the longest available follow-up assessment of PTSD symptom severity measured on a continuous validated calibration, or using structured interviews assessing PTSD symptoms according to diagnostic criteria. In improver to the longest available follow-up, we assessed handling effects immediately afterward handling termination (⩽1 month afterward treatment termination) and long-term effects (>one month afterward termination). If more than i PTSD scale was used in the trial, nosotros used a predefined hierarchy, which gave most oftentimes used scales precedence (see eAppendix 2 for the pre-defined hierarchy). Results from intention-to-care for (ITT) analyses were preferred over results from per-protocol or completer analyses, and observer-rated outcomes were used in our analyses only if self-rated outcomes were not reported. As secondary outcome we included the acceptability of PTSD treatments every bit indicated by patients dropping out of treatment before handling termination. If no reasons for early on termination were provided, nosotros used the total drib-out rates per group.
Information collection
For the outcome size calculation, nosotros extracted sample sizes (N), means (M) and standard deviations (s.d.) for each treatment group. In case these values were missing, other statistical data that can exist converted into ways and standard deviations were extracted. Conversions were calculated according to formulas previously suggested (Cohen, Reference Cohen1988; Higgins & Green, updated March Reference Higgins and Greenish2011; Lakens, Reference Lakens2013; Lipsey & Wilson, Reference Lipsey and Wilson2001). If the Northward was missing in the tabular array of assay, nosotros used the N of the descriptive statistics, and if group Ns were missing, nosotros assumed same sample size per group. Nosotros contacted one study author, because insufficient information was bachelor, simply the author did not reply. Studies were excluded, if the outcome data could not exist calculated, imputed, or obtained from the authors. For the calculation of gamble ratios (RRs) as indicators of treatment acceptability we extracted the number of driblet-outs betwixt beginning and end of handling.
In addition to the data for effect size adding characteristics of the included population (e.m. type of trauma, age of the study sample, PTSD diagnosis), the intervention (e.g. number of handling sessions, reference to the original Pennebaker writing prototype, presence of a therapist during writing sessions, location of writing), and the report (e.grand. year of publication) were coded. We rated gamble of bias for the results presented in each individual included written report using the dimensions divers in the Cochrane Hazard of Bias (RoB) Assessment Tool (Higgins & Green, updated March Reference Higgins and Green2011). Across studies we rated the indirectness of the available prove (i.due east. whether a unmarried study differed from the target studies nosotros were interested in with respect to population, intervention, outcome assessment, or the type of comparison; Guyatt et al., Reference Guyatt, Oxman, Kunz, Woodcock, Brozek, Helfand and Vist2011). In social club to rate the confidence in the entire network meta-analytic results on a meta-level across all included studies we used the Movie theatre framework (Salanti, Del Giovane, Chaimani, Caldwell, & Higgins, Reference Salanti, Del Giovane, Chaimani, Caldwell and Higgins2014) (meet eAppendix 2 for a detailed clarification of ratings for RoB, indirectness, and network confidence). Two contained raters (HG and CW) extracted all data from all included studies on a standardized form (Microsoft Office Excel 2011 and 2018) afterwards intensive training in using the transmission with operational descriptions of each item. Disagreements were solved by consensus between these 2 raters.
Data analysis
Standardized mean differences (SMDs) were calculated first with the information collected at the end of treatment (34 studies), and 2d with the information from long-term follow-upward (26 studies). In our analyses using the longest bachelor follow-up data we included all 44 identified studies with a preference for long-term information if both, end of treatment and long-term information, were bachelor. In our protocol, we divers the analyses using short-term data as primary outcomes. This choice was fabricated considering we expected that all studies would report results at the stop of treatment and we wanted the main analyses to include all available studies. Reverse to our expectations, several studies reported long-term follow-up information only. Therefore, we decided to apply the almost complete results using the longest available follow-upwards data as primary consequence (i.eastward. we used these data for subsequent explorations of heterogeneity and robustness of findings in our sensitivity analyses). However, in accord with the protocol, nosotros report all results, using brusk-term data only (34 studies), long-term information only (26 studies), and using all bachelor data (i.e. the longest available follow-upward from 44 studies). The magnitude of SMD was interpreted equally pocket-sized (0.20 due south.d. units), moderate (0.50 s.d. units), or large (0.80 southward.d. units; Cohen, Reference Cohen1988). RRs were calculated for the drib-out rates between start and finish of treatment: losses to follow-upwards were not considered. We used a 2-sided p < 0.05 to indicate statistical significance.
A network was created including 5 jointly randomizable treatments: 1st expressive writing (original; EW), 2nd enhanced expressive writing (EW+), 3rd PTSD psychotherapies (PT), and we included 4th neutral writing controls (NW), and fiveth waiting listing controls (WL). Network geometry was summarized in a graph which presents the five treatments as nodes (larger nodes point a larger number of studies per treatment), and the available comparisons between treatments as edges between the nodes (the thickness of the edges represents the number of available comparisons). We assumed that whatever patient that meets all inclusion criteria is likely, in principle, to be randomized to any of the interventions in the synthesis comparator set. We addressed the assumption of transitivity in the network meta-analysis (Salanti, Reference Salanti2012), by 1st assessing whether the included interventions are similar across studies using a different design, and 2nd checking whether the distribution of potential moderators is balanced across comparisons (Jansen & Naci, Reference Jansen and Naci2013).
We considered random-furnishings models rather than a fixed-upshot model because the included studies were unlike with respect to clinical and other factors (encounter eTable 1). SMDs were calculated for all relevant comparisons within each study. In add-on, indirect testify was estimated using the unabridged network of show. To conduct network meta-analyses inside a frequentist framework we used the package netmeta version 0.9–7 (RĂĽcker, Schwarzer, Krahn, & König, Reference RĂĽcker, Schwarzer, Krahn and König2018) for the open-source software environment R (version 3.5.1; R Cadre Team, 2018). The R part pairwise transformed the dataset to the dissimilarity-based format, which is needed for conducting the network meta-analysis.
To express heterogeneity between studies the Q statistic was used (Cochran, Reference Cochran1950). Further Ď„ two was calculated to get an estimate of the variance between studies (Higgins, Reference Higgins2008). For the primary event a value of Ď„ two = 0.04 was considered as low heterogeneity, 0.09 as moderate and 0.16 equally high heterogeneity (Borenstein, Hedges, Higgins, & Rothstein, Reference Borenstein, Hedges, Higgins and Rothstein2011). In addition we used I2 equally an indicator of the amount of observed variance that can be attributed to between-study heterogeneity (Higgins, Thompson, Deeks, & Altman, Reference Higgins, Thompson, Deeks and Altman2003) which can roughly be interpreted as follows: 0%–forty%: might not be important; 30%–60%: may correspond moderate heterogeneity; l%–ninety%: may represent substantial heterogeneity; 75%–100%: considerable heterogeneity (Borenstein et al., Reference Borenstein, Hedges, Higgins and Rothstein2011). In the network meta-analyses, we assumed a common estimate for the between-written report heterogeneity variance beyond all included comparisons.
We used local, equally well as global methods to detect inconsistency in the network (Efthimiou et al., Reference Efthimiou, Debray, van Valkenhoef, Trelle, Panayidou and Moons2016): 1st locally using the netsplit command (i.eastward. splitting direct and indirect evidence), and 2nd globally using the decomp.design command (i.e. using the pattern-by-treatment interaction model). Nosotros compared the magnitude of heterogeneity between consistency and inconsistency models to determine how much of the total heterogeneity was explained by inconsistency.
We conducted sensitivity analyses excluding studies with imputed standard deviations, studies with high indirectness ratings, studies that reported only observer-rated outcomes, studies that did not employ established merely rather experimental PTSD psychotherapies, and studies that included only patients who reported PTSD symptoms only not full or fractional PTSD, in guild to test the robustness of results.
Results
The systematic database search identified 5439 records. Following the title and abstruse screening 119 total-text articles were considered potentially relevant. Notwithstanding, 44 RCTs* with a full of 7724 participants were included in our analyses (come across Fig. 1). 9 included studies were publicly available dissertation theses. All included studies were published between 1996 and 2018, and were bachelor in English. The fourth dimension to concluding bachelor follow-upwards ranged between 7 and 420 days with a median of 42 days (encounter eTable 1), and longer intervals for the last follow-up assessment were observed in studies with enhanced writing and psychotherapy (encounter eTable 2). Xl-one studies reported self-rated outcomes and 3 studies reported only observer-rated outcomes, two of which reported acceptable blinding of outcome assessors, in one report with observer-rated outcomes we found no data regarding blinding of outcome assessors. Six studies used psychotherapeutic PTSD treatments as comparator including cognitive behavioural treatment (CBT) in one report, cerebral processing therapy (CPT) in two studies (Resick et al., Reference Resick, Galovski, Uhlmansiek, Scher, Clum and Immature-Xu2008; Sloan, Marx, Lee, & Resick, Reference Sloan, Marx, Lee and Resick2018; van Emmerik, Kamphuis, & Emmelkamp, Reference van Emmerik, Kamphuis and Emmelkamp2008), heart motility desensitization and reprocessing (EMDR) in 1 study (Largo-Marsh, Reference Largo-Marsh1996; Largo-Marsh & Spates, Reference Largo-Marsh and Spates2002), one study applied a psychotherapeutic approach described as active facilitator disclosure (Slavin-Spenny, Cohen, Oberleitner, & Lumley, Reference Slavin-Spenny, Cohen, Oberleitner and Lumley2011), which includes talking about the trauma feel and the emotions relating to that experience, every bit well equally the identification of missing content in the participant's story, and one study practical a highly directive protocol aimed at promoting evidence-based processes to improve PTSD symptoms (Alessandri, Reference Alessandri2017). In iv studies experimental manipulations of the writing epitome (eastward.grand. instruction to focus on emotion 5. on insights) were applied in add-on to NW every bit control. In these cases, nosotros combined the groups that used experimental manipulations (encounter eTable one). In studies with psychotherapeutic PTSD treatments or waiting list control as comparator the proportion of participants with full or partial PTSD was larger (83.3% and 66.7%, respectively) than in the studies that used writing assignments as treatment (33.3% for EW and 32% for EW+) and neutral writing as comparator (30.four%; see eTable ii).
Fig. ane. Flow chart of study inclusion.
We identified a network of treatments in which comparisons were bachelor for all possible treatment combinations. This allowed for estimating inconsistency betwixt direct and indirect prove for each comparison. See Fig. 2 for the identified network of comparisons and eTable 1 for additional characteristics of the included studies.
Fig. ii. Network of included comparisons. The size of the nodes indicates the number of studies per treatment. The thickness of the edges represents the number of comparisons between two treatment approaches.
RoB was considered moderate in 14 studies and high in 30 studies (eTable 3). Indirectness was considered low in eight studies, moderate in 27 studies and high in ix studies (eTable 4). The network meta-analyses relied generally on evidence with moderate to loftier RoB and with moderate indirectness (meet eFigs 1 and 2). Conviction in the network meta-analyses was considered moderate for ane comparing and low for three comparisons (i.e. EW v. NW, EW+ v. WL, and EW+ 5. PT; eTable 5).
Nosotros checked for baseline differences between PTSD scores and found PTSD scores to be significantly smaller in the EW+ groups compared with the WL groups with an SMD of −0.12 (95% CI −0.23 to −0.02; see Tabular array 1 and eAppendix 3).
Table ane. Comparative efficacy between active treatments and waiting list across different (sensitivity) analyses from network meta-analyses (SMD and 95% CI)
Comparative efficacy
At the cease of treatment EW+ and PT were significantly more efficacious than EW, NW, and WL in reducing PTSD symptoms (Fig. 3a), and there were no pregnant differences between EW, NW, and WL observed (Fig. 3a and Table one). We establish evidence for very big between study heterogeneity (Ď„ ii = 0.17) and significant inconsistency (Q = 14.78; df = 4; p = 0.005).
Fig. 3. Comparative efficacy of expressive writing as compared with active and passive comparators. Results (SMD and 95% CI) on the comparative efficacy from network meta-analyses (grey) and from standard pairwise meta-analyses (white) at the end of treatment (a), at longest bachelor follow-up including all 44 RCTs (b), and from the exploratory analyses excluding two-arm studies which directly compared EW+ with WL (c). To brand network and pairwise meta-assay results directly comparable, estimates are presented every bit column v. row for the network meta-analyses, and row five. cavalcade for the pairwise meta-analyses. Statistically significant results are printed in bold. EW, expressive writing; EW+, enhanced writing; CI, confidence interval; NW, neutral writing; PT, psychotherapy; SMD, standardised hateful deviation; WL, waiting listing.
At the longest available follow-up superiority of EW+ and PT over EW, NW, and WL decreased slightly but was still statistically meaning (Fig. 3b; Table one). Too, EW and NW showed moderately sized significant superiority over WL in the long-term. We constitute moderate heterogeneity (Ď„ ii = 0.08) and significant inconsistency (Q = 49.23; df = 10; p < 0.0001; eAppendix iv) in this assay. Sensitivity analyses indicated some variation in the observed SMDs (Tabular array 1). The general design of results, all the same, shows significant superiority of all active treatment groups over WL, and small to moderate differences between the active treatment groups (eAppendix five). Pairwise meta-analyses confirmed this overall pattern (Figs 3a and b; eAppendix six).
Exploratory findings excluding two-arm comparisons between EW+ and WL
In a post-hoc analysis nosotros excluded 2-arm studies that compared EW+ with WL because of the finding of meaning baseline differences in this comparison (Table one) and the ascertainment that this comparison contributed considerably to the inconsistency observed in the network meta-assay (meet eAppendix 4). This analysis showed pocket-sized to moderate significant superiority of all agile treatments over WL (Fig. threec; Table ane). PT was significantly superior over NW, and no significant differences were found between EW+, EW, and NW using longest available follow-up data (Fig. 3c). Heterogeneity was low to moderate in this analysis (Ď„ 2 = 0.05) and inconsistency was reduced merely yet meaning (Q = 18.28; df = ix; p = 0.03).
Comparative acceptability
With respect to the acceptability of treatments we observed significantly more than drop-outs in PT as compared with WL (RR = 2.05, 1.04 to 4.04; Fig. 4). Betwixt EW+, EW, NW, and WL no significant differences were observed (Fig. 4; eAppendix 7). We found depression to moderate heterogeneity (Ď„ 2 = 0.05) and statistically non-meaning inconsistency (Q = 3.28; df = 6; p = 0.77). Pairwise meta-analyses confirmed the statistically non-significant differences in drop-outs betwixt the different treatment approaches (Fig. iv; eAppendix 8).
Fig. 4. Comparative acceptability of expressive writing as compared with agile and passive comparators. Results (RR and 95% CI) based on drib-out rates betwixt beginning and end of treatment from network meta-analyses (grayness) and standard pairwise meta-analyses (white). To make network and pairwise meta-analysis results straight comparable, estimates are presented as column 5. row for the network meta-analyses, and row five. column for the pairwise meta-analyses. Statistically meaning results are printed in bold. EW, expressive writing; EW+, enhanced writing; CI, confidence interval; NW, neutral writing; PT, psychotherapy; RR, relative risk; WL, waiting list.
Discussion
Our network meta-analysis addresses the comparative efficacy between expressive writing treatments equally compared with psychotherapeutic PTSD treatments, neutral writing treatment and waiting list controls. In order to consider recent developments in writing treatments we classified them into those that referred to the original paradigm developed past Pennebaker & Beall (EW) and those that included additional elements causeless to increase their efficacy (i.e. therapist contact and more elaborated and structured instructions for the individual writing sessions; EW+). To the best of our knowledge this is the near comprehensive summary of RCTs on the efficacy of writing treatments on PTSD symptoms so-far. Using network-meta-analysis we were able to include all available comparisons between writing treatments and active likewise equally passive comparators in i statistical model. From a clinical perspective it is important to consider that about of the studies which used EW and EW+ every bit treatment included trauma survivors who reported some PTSD symptoms, simply who would not qualify for a partial or full PTSD diagnosis.
Our results show that in the short-term EW+ and PT significantly outperformed EW, NW and WL, with EW and NW showing simply small and non-pregnant superiority over WL. In the long-term, however, all active treatments outperformed WL significantly, with EW+ and PT again significantly outperforming EW and NW. It is important to note that the average duration of treatment and the number of handling sessions were considerably higher in EW+ and PT equally compared with EW and NW (meet eTable 2). Thus, the amount of time spent in treatment is confounded with the type of treatment. Our analyses practice not permit for conclusions whether the actual content of EW+ and PT or the time spent in treatment contributed near to the treatments' effects. The observed superiority of EW+ and PT was modest to moderate and probably not of clinical significance (Stefanovics, Rosenheck, Jones, Huang, & Krystal, Reference Stefanovics, Rosenheck, Jones, Huang and Krystal2018). We establish evidence for significantly more than drop-out in PT as compared with WL. Although we aimed to excerpt data on treatment drib-outs only (equally opposed to more general losses to follow-up), a huge variability in definitions and the reporting of drib-outs, just also different reasons for dropping out (east.g. occurrence of adverse effects v. symptom comeback) complicate data extraction, and in turn interpretations of these data with respect to handling acceptability. Our analyses, including several sensitivity analyses, showed considerable variability betwixt results from individual studies, every bit indicated by between report heterogeneity, only there were likewise differences betwixt direct and indirect estimates of comparative efficacy, as indicated by significant inconsistency.
Based on previous reports (Mylle & Maes, Reference Mylle and Maes2004; Pavlacic, Buchanan, Maxwell, Hopke, & Schulenberg, Reference Pavlacic, Buchanan, Maxwell, Hopke and Schulenberg2019; Pietrzak et al., Reference Pietrzak, Goldstein, Southwick and Grant2011, Reference Pietrzak, Goldstein, Southwick and Grant2012) nosotros conducted a sensitivity assay in which we excluded studies which had reported only increased levels of PTSD symptoms (as opposed to total or partial PTSD diagnoses). Nosotros establish somewhat larger result sizes of PT, EW+ and EW in this assay as compared to the master analysis, but also a considerable increase in heterogeneity, which hampers clear conclusions based on this analysis. Due to the observation that the studies comparing EW+ with WL showed significant differences at baseline already, and the observation that this particular comparing contributed considerably to network inconsistency, nosotros conducted an exploratory analysis in which we excluded this corresponding comparing from the network. In this analysis, the superiority of EW+ and PT compared to EW, NW and WL was considerably reduced and superiority of EW+ and PT over EW and NW were no longer statistically meaning. In this analysis heterogeneity was reduced to a pocket-size to moderate level.
Thus, when discussing our study findings, the studies comparing EW+ with WL need some additional attention. In full general, the issues associated with the use of WL equally control in psychotherapy RCTs has been described previously (Cuijpers & Cristea, Reference Cuijpers and Cristea2016; Eysenck, Reference Eysenck and Giles1993; Furukawa et al., Reference Furukawa, Noma, Caldwell, Honyashiki, Shinohara, Imai and Churchill2014; Staines & Cleland, Reference Staines and Cleland2007). Unfortunately, despite the availability of a credible agile control treatment in RCTs on writing treatments (i.e. the neutral writing command), which has typically been used in the earlier trials, more than recent RCTs increasingly implemented WL equally comparator. Accordingly, later on excluding comparisons betwixt EW+ and WL ix out of xv RCTs using EW+ had to be excluded from the analyses. In addition to the issues associated with the utilise of WL controls, the nine two-arm RCTs using EW+ as treatment and WL as control are also prone to the then-called investigator or researcher allegiance bias. In all nine studies the authors were involved in the evolution of the EW+ handling protocol, one of the strongest indicators of researcher fidelity (Munder, Gerger, Trelle, & Barth, Reference Munder, Gerger, Trelle and Barth2011). The presence of potent researcher preferences in favour of the investigated treatment take been shown to exist associated with larger benefits of the preferred handling in psychotherapy RCTs (Gerger & Gaab, Reference Gerger and Gaab2016; Munder, BrĂĽtsch, Leonhart, Gerger, & Barth, Reference Munder, BrĂĽtsch, Leonhart, Gerger and Barth2013), and this clan has been shown to be mediated by low methodological quality of the RCTs (Munder et al., Reference Munder, Gerger, Trelle and Barth2011). The choice of WL as comparator, instead of using a more than credible active comparator may contribute to such bias.
Strengths and limitations
In network meta-analyses multiple comparisons between more than than ii treatment approaches are integrated in one assay. This provides a more than comprehensive overview regarding the comparative efficacy and acceptability of writing treatments in comparing to other treatment options, simply also compared to passive and active comparators. This analytic approach immune the states to detect potential differences in the efficacy of the original and adapted writing treatments, and to check whether results are consistent beyond different research designs. We reduced the gamble for the occurrence of publication bias by including published enquiry articles but also publicly available dissertation theses. In social club to warrant transitivity in the network we included only studies in which participants were randomly assigned to a writing intervention in at least one treatment group and to an boosted comparator. We did however non include studies which directly compared only a psychotherapeutic PTSD treatment with a control treatment (e.1000. waiting listing) equally these studies might differ from the writing intervention studies regarding clinical or methodological characteristics. Regarding the combination of different psychotherapeutic PTSD treatments in one node of the network, one could question whether the PTSD psychotherapies were like enough with respect to their effects in order to be combined. A previous network meta-analysis demonstrated that at that place were no significant differences between treatment effects of EMDR, CBT, and CPT (Gerger et al., Reference Gerger, Munder, Gemperli, NĂĽesch, Trelle, JĂĽni and Barth2014). A sensitivity assay in which nosotros excluded 2 studies which used newly developed psychotherapeutic treatments (i.eastward. directive protocol and active facilitator writing) replicated the findings using all v studies which used psychotherapeutic PTSD treatments every bit comparators.
The almost relevant limitation of our study is the observed heterogeneity and inconsistency. Even so, this observation reflects the multifariousness of findings reported in previous meta-analyses (Frattaroli, Reference Frattaroli2006; Frisina et al., Reference Frisina, Borod and Lepore2004; Mogk et al., Reference Mogk, Otte, Reinhold-Hurley and Kröner-Herwig2006; Smyth, Reference Smyth1998; Smyth & Pennebaker, Reference Smyth and Pennebaker2008; van Emmerik et al., Reference van Emmerik, Reijntjes and Kamphuis2013). Unfortunately, even using the currently most elaborate statistical approach to summarize available enquiry evidence (i.e. network meta-analysis) did not provide results that let definite conclusions. However, using network meta-analysis we were able to show, that the superiority of PT and EW+ might be overestimated when 1st focusing on short-term results only, and 2nd when including mainly comparisons between EW+ and WL. A further limitation of our study is that nosotros focused only on PTSD symptoms and treatment credence as outcomes, merely ignored additional potentially relevant outcomes, for case well-being, equally well every bit additional indicators of potential harm, for instance agin events.
Information technology is of import to annotation, that many of the included studies have to be considered underpowered, equally a minimum of 64 participants per group would exist needed in an RCT comparing a treatment with an active comparator and expecting a medium SMD of 0.l with a desired ability of 0.fourscore and a two-tailed p of 0.05 (Schnurr, Reference Schnurr2007). The inclusion of underpowered trials in a meta-analysis increases the risk of biased results, partly due to the fact that underpowered studies with negative or non-significant findings have a smaller chance of being published (contributing to the then-called publication bias). We tried to minimize the affect of publication bias by including unpublished studies in addition to studies which were published in scientific journals.
Conclusions
In our network meta-analysis using data from the longest bachelor follow-up assessments all active treatments (including NW) outperformed WL with pocket-size to moderate superiority of trauma-focused treatments (i.due east. PT, EW+, EW) over NW. We constitute only pocket-size to moderate superiority of PT and EW+ over EW, which was statistically significant in some analyses, but probably non of clinical significance. Nosotros conclude that every bit it stands methodological issues to a considerable extent might explain the observed superiority of EW+ over EW. Definite conclusions are hampered to-engagement because of the predominant use of WL controls in EW+ RCTs, the lack of direct comparisons betwixt the original EW and recently adult EW+, every bit well as a lack of RCTs investigating EW+ efficacy, which are conducted by independent researchers. Thus, particularly the superiority of EW+ over the original EW paradigm only also over NW controls await confirmation from fairly sized comparative RCTs preferably including all 4 agile treatment approaches (i.e. EW, EW+, PT, and NW), reporting long-term data and including researchers with balanced preferences.
From a clinical perspective the potential of writing interventions to fill up treatment gaps in mental health care by offer the possibility to treat patients with but minimal therapist contact is highly relevant and our analyses ostend pregnant benefits of writing treatments in improving PTSD symptoms. However, to date no definite conclusions are possible regarding the exact magnitude of these benefits, the increase in benefits by enhancing expressive writing with additional handling components, and the effectiveness of writing treatments in comparing with PTSD psychotherapies.
Acknowledgements
Nosotros would like to thank Franziska Z'graggen who conducted a airplane pilot study for this network meta-analysis.
Writer contributions
Dr Gerger had full admission to all the data in the study and took responsibility for the integrity of the information and the accurateness of the data analysis. Gerger and Werner conceptualized and designed the study. Cuijpers, Gaab, Gerger, and Werner acquired, analysed or interpreted data. Gerger and Werner drafted the manuscript. Cuijpers, Gaab, Gerger, and Werner critically revised the manuscript for of import intellectual content. Gerger performed statistical analyses. Gerger supervised the written report.
Conflict of interest
The authors declare no conflicts of interest.
Ethical standards
Every bit the written report did not involve homo subjects no ethical blessing was necessary.
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Source: https://www.cambridge.org/core/journals/psychological-medicine/article/comparative-efficacy-and-acceptability-of-expressive-writing-treatments-compared-with-psychotherapy-other-writing-treatments-and-waiting-list-control-for-adult-trauma-survivors-a-systematic-review-and-network-metaanalysis/4F51866CCE7E56ABBA38DF064780BEA2
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