A Systematic Review and Meta-Analysis of Predictors of Response to Trauma-Focused Psychotherapy for Posttraumatic Stress Disorder

Although trauma-focused psychotherapy (T-F psychotherapy) is the treatment of choice for posttraumatic stress disorder (PTSD), up to one half of patients do not respond to this treatment. Attempts to improve response to T-F psychotherapy have focused on augmenting fear extinction-based factors. Here, a systematic and meta-analytic review of predictors of T-F psychotherapy outcome was conducted with the goal of using an aggregate data-driven approach to elucidate baseline factors associated with treatment outcome. There were 114 studies that met inclusion criteria (N = 61, 970; M-age = 40.1 years; 40.1% female). There were 237 effect sizes across 24 meta-analytic categories. Poorer treatment response is associated with lower pretreatment levels of activation of fear-related brain regions, psychophysiological reactivity to fear provocation, trauma-related cognitions, anger, depression, high-risk alleles of genes linked to fear, lower levels of executive control, and social support. A range of other factors also predicted poorer responses including being male, non-Caucasian, older in age, early trauma occurrence, more trauma experience, history of combat trauma, as well as comorbid sleep, pain, poor quality life, and alcohol abuse difficulties. This review provides one potential explanation for the limited success of T-F psychotherapy augmentation strategies that have focused only on fear circuity mechanisms at the exclusion of other factors. Here, poor response relating to predictors of early trauma onset and comorbidity are consistent with clinical presentations of complex PTSD, which may suggest T-F psychotherapy is less effective for this condition. This collective evidence suggests that clinicians should consider a tailored approach that targets potential barriers to successful treatment response.