Non-pharmacological therapies for the treatment of post-traumatic stress disorder among emergency responders: a scoping review

Nascimento, Jessica Cristhyane Peixoto; Santos, Kauanny Vitoria Gurgel dos; Dantas, Joyce Karolayne dos Santos; Dantas, Daniele Vieira; Dantas, Rodrigo Assis Neves

doi:10.1590/S1980-220X2020011603724

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REVIEW • Rev. esc. enferm. USP 55 • 2021 • https://doi.org/10.1590/S1980-220X2020011603724 copy

Non-pharmacological therapies for the treatment of post-traumatic stress disorder among emergency responders: a scoping review

Terapias no farmacológicas de tratamiento del trastorno de estrés postraumático en emergencistas: revisión de alcance

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

Identify non-pharmacological therapies for the treatment of post-traumatic stress disorder in emergency responders.

Method:

Scope review according to the guidelines of the Joanna Briggs Institute and the PRISMA-ScR protocol. A search was conducted in nine databases, portals of theses and dissertations, and using an electronic search engine.

Results:

In total, 23 studies were selected and analyzed, and then categorized into six thematic fields - therapy with omega 3 food supplement, art therapy, physical exercise therapy, mindfulness-based therapy, therapy with elements of nature, and psychotherapy - which were considered non-pharmacological treatments for this psychopathology among emergency responders, as well as the use of psychotherapy via telehealth as an option for treatment.

Conclusion:

More evidence supporting diet therapy is required, while the other therapeutic options presented positive results, finding support in national and international recommendations of treatment and clinical practice.

DESCRIPTORS:
Stress Disorders, Post-Traumatic; Emergency Responders; Complementary Therapies; Emergency Nursing; Review

Database	Syntax adopted
WOS^* * Web of Science, †Sciverse Scopus, ‡Cumulative Index to Nursing and Allied Health Literature, §Medical Literature Analysis and Retrieval System Online, \|\|PTSDpubs Database.	TS=(Therapy OR Therapeutics OR Disease Management OR Complementary Therapies) AND TS=(Stress Disorders, Post-Traumatic OR PTSD) AND TS=(Occupational Diseases OR Occupational Stress OR Emergency Responders OR Rescue Workers OR Rescue Work)
Scopus†	(KEY ("Therapy" OR "Therapeutics" OR "Disease Management" OR "Complementary Therapies") AND KEY ("Stress Disorders, Post-Traumatic" OR "PTSD") AND KEY ("Occupational Diseases" OR "Occupational Stress" OR "Emergency Responders" OR "Rescue Workers" OR "Rescue Work"))
CINAHL‡	(SU (Therapy OR Therapeutics OR Disease Management OR Complementary Therapies)) AND (SU (Stress Disorders, Post-Traumatic OR PTSD)) AND (SU (Occupational Diseases OR Occupational Stress OR Emergency Responders OR Rescue Workers OR Rescue Work))
PsycINFO§	(MeSH: Therapy OR MeSH: Therapeutics OR MeSH: Disease Management OR MeSH: Complementary Therapies) AND (MeSH: Stress Disorders, Post- Traumatic OR MeSH: PTSD) AND (MeSH: Occupational Diseases OR MeSH: Occupational Stress OR MeSH: Emergency Responders OR MeSH: Rescue Workers OR MeSH: Rescue Work)
MEDLINE\|\|	((((therapeutics[MeSH Terms]) OR (disease management[MeSH Terms])) OR (complementary therapies[MeSH Terms])) AND ((post traumatic stress disorders[MeSH Terms]) OR (PSTD[MeSH Terms])) AND ((occupational diseases[MeSH Terms]) OR (occupational stress[MeSH Terms]) OR (rescue work[MeSH Terms]) OR (emergency responders[MeSH Terms]))))
PTSDpubs \|\|	("Therapy" OR "Therapeuthics" OR "Disease Management"OR "Complementary Therapies") AND ("Stress Disorders, Post-Traumatic" OR "PTSD") AND ("Occupational Diseases" OR "Occupational Stress" OR "Emergency Responders"OR "Rescue Workers" OR "Rescue Work")

Authors/ country	Intervention and target audience	Outcome	Study design/ Level of evidence/ Degree of recommendation⁽¹⁶16 Centre for Evidence-Based Medicine. Levels of evidence [Internet]. Washington: CDC; 2009 [cited 2020 July 29]. Available from: https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/ https://www.cebm.net/2009/06/oxford-cent... ⁾)
Alghamdi et al.⁽¹⁷17 Alghamdi M, Hunt N, Thomas S. The effectiveness of narrative exposure therapy with traumatised firefighters in Saudi Arabia: a randomized controlled study. Behav Res Ther. 2015; 66:64-71. doi: https://doi.org/10.1016/j.brat.2015.01.008 https://doi.org/10.1016/j.brat.2015.01.0... ⁾/ Saudi Arabia	Narrative exposure therapy with firefighters (n=34). Four 60-90 minute sessions in 3 weeks.	Reduction in PTSD symptom scores. Results not maintained after 3 and 6 months.	Randomized controlled clinical trial / 1B / A.
Bryant et al.⁽¹⁸18 Bryant RA, Kenny L, Rawson N, Cahill C. Efficacy of exposure-based cognitive behaviour therapy for post-traumatic stress disorder in emergency service personnel: a randomised clinical trial. Psychol Med. 2019;49(9):1565-73. doi: https://doi.org/10.1017/S0033291718002234 https://doi.org/10.1017/S003329171800223... ⁾/ England	Cognitive behavioral therapy with emergency responders (n=100). Weekly sessions for 12 weeks.	Reduction in PTSD symptom scores, anxiety and maladaptation.	Randomized controlled clinical trial / 1B / A.
Gersons et al.⁽¹⁹19 Gersons BPR, Carlier IVE, Lamberts RD, Kolk BAVD. Randomized clinical trial of brief eclectic psychotherapy for police officers with posttraumatic stress disorder. J Trauma Stress. 2000;13(2):333-47. doi: https://doi.org/10.1023/A:1007793803627 https://doi.org/10.1023/A:1007793803627... ⁾/ the Netherlands	Brief eclectic psychotherapy comprised of psychoeducation, imaginary guidance, writing assignments and memories, domain of meaning or integration, and a farewell ritual for police officers (n=42). Weekly 60-90 minute sessions for 16 weeks.	Reduction in PTSD symptom scores, with sustained improvement after 3 months of treatment.	Randomized noncontrolled clinical trial / 2B / B.
Haugen et al.⁽²⁰20 Haugen PT, Evces T, Weiss DS. Treating posttraumatic stress disorder in first responders: a systematic review. Clin Psychol Rev. 2012;32(5):3 70-80. doi: https://doi.org/10.1016/j.cpr.2012.04.001 https://doi.org/10.1016/j.cpr.2012.04.00... ⁾/ USA	Cognitive therapy associated with virtual reality with police officers, firefighters and lay rescuers (n=21); eye movement desensitization and reprocessing (EMDR) with police officers (n=62); therapy of behavioral activation and prolonged exposure in police officers (n=1); combination of cognitive behavioral therapy and eclectic psychotherapy with police officers (n=42).	Reduction in PTSD symptom scores in most studies. Except for one study that published an expert opinion about EMDR.	Systematic review with no meta-analysis / 2A / B.
Hauger et al.⁽²¹21 Hauger PT, Splaun AK, Evces MR, Weiss DS. Integrative approach for the treatment of posttraumatic stress disorder in 9/11 first responders: three core techniques. Psychotherapy (Chic). 2013;50(3):336-40. doi: https://doi.org/10.1037/a0032526 https://doi.org/10.1037/a0032526... ⁾/ USA	Cognitive behavioral therapy - integrative psychotherapy comprising emphasis on the generation of meaning, focus on the components with major impact from traumatic exposure, identification and challenge of implicit strategies with lay rescuers, police officers and firefighters, offered weekly.	Restored 'sense of purpose in life' and 'hope for the future.'	Case report / 4 / C.
Haugen et al.⁽²²22 Haugen P, Goldman R, Owen J. Sudden gains and deteriorations in the treatment of posttraumatic stress disorder in World Trade Center responders. J Nerv Ment Dis. 2015; 203(3):205-9. doi: https://doi.org/10.1097/NMD.0000000000000263 https://doi.org/10.1097/NMD.000000000000... ⁾/ USA	Integrative psychotherapy with elements of psychodynamics and cognitive behavioral therapy in police officers, firefighters, rescuers (n=36). Weekly sessions for 3-15 weeks	Reduction in PTSD symptom scores in most participants. About 1/3 of them presented worsened symptoms after 3 sessions.	Exploratory cohort / 2B / B.
Lansing et al.⁽²³23 Lansing K, Amen DG, Hanks C, Rudy L. High-resolution brain SPECT imaging and eye movement desensitization and reprocessing in police officers with PTSD. J Neuropsychiatry Clin Neurosci. 2005;1 0(1):526-32. doi: https://doi.org/10.1176/jnp.17.4.526 https://doi.org/10.1176/jnp.17.4.526... ⁾/ USA	EMDR in police officers (n=6); 3 3-4 hour sessions.	Reduction in PTSD symptom scores. Changes in brain imaging tests.	Randomized noncontrolled clinical trial / 2B / B.
Lewis-Schroeder et al.⁽²⁴24 Lewis-Schroeder NF, Kieran KNP, Murphy BLMD, Wolff JDBS, Robinson MA, Kaufman MLMD. Conceptualization, assessment, and treatment of traumatic stress in first responders: a review of critical issues. Harv Rev Psychiatry. 2018;26(4):21 6-27. doi: https://doi.org/10.1097/HRP.0000000000000176 https://doi.org/10.1097/HRP.000000000000... ⁾/ England	Cognitive processing therapy, prolonged exposure therapy, and EMDR in emergency responders, prehospital professionals, paramedics, firefighters, and law enforcement officers. Weekly sessions for 12 weeks.	Reduction in PTSD symptom scores.	Integrative review with analysis of results / 2C / B.
Nishi et al.⁽²⁵25 Nishi D, Koido Y, Nakaya N, Noguchi H, Hamazaki K, Hamazaki T, et al. Fish oil for attenuating posttraumatic stress symptoms among rescue workers after the great east Japan earthquake: a randomized controlled trial. Psychother Psychosom. 2012;81:315-7. doi: https://doi.org/10.1159/000336811 https://doi.org/10.1159/000336811... ⁾/ Japan	Fish oil supplementation to relieve PTSD symptoms in emergency physicians and nurses, lay rescuers and mobile medical team who worked in the Great East Japan earthquake (n=450). Seven 320 mg capsules of omega 3 were administered daily for 12 weeks.	The study did not demonstrate superiority of supplementation with fish oil + psychoeducation over psychoeducation in reducing PTSD symptom scores. Fish oil played an important role in regulating psychological well-being in women.	Randomized controlled clinical trial / 1B / A.
Olden et al.⁽²⁶26 Olden M, Wyka K, Cukor J, Peskin M, Altemus M, Lee F. Pilot study of a telehealth-delivered medication-augmented exposure therapy protocol for PTSD. J Nerv Ment Dis. 2017; 205(2):154-160. doi: https://doi.org/10.1097/NMD.0000000000000563 https://doi.org/10.1097/NMD.000000000000... ⁾/ USA	Exposure therapy via telehealth video conferencing for firefighters, police, emergency and military personnel (n=7). Weekly 90-minute sessions for 12-15 weeks.	Reduction in PTSD symptom scores.	Randomized noncontrolled clinical trial / 2B / B.
Richards, Rose⁽²⁷27 Richards, DA, Rose, JS. Exposure therapy for post-traumatic stress disorder: four case studies. Br J Psychiatry. 1991;158(6):836-40. doi: https://doi.org/10.1192/bjp.158.6.836 https://doi.org/10.1192/bjp.158.6.836... ⁾/ England	Cognitive behavioral therapy - in vivo exposure and image exposure among police officers, one electrician and one civilian (n=4). One weekly session of 60 to 90 minutes for 7-11 weeks.	Reduction in PTSD symptom scores.	Case report / 4 / C
Ressler, Mayberg⁽²⁸28 Ressler KJ, Mayberg HS. Targeting abnormal neural circuits in mood and anxiety disorders: from the laboratory to the clinic. Nat Neurosci. 2007;10:1116-24. doi: https://doi.org/10.1038/nn1944 https://doi.org/10.1038/nn1944... ⁾/ USA	Art therapy - assembly of paintings and written expression with military personnel (n=240). Weekly group sessions, for 4 weeks.	Stronger feelings of hope, positive emotions, socialization, self-awareness of psychological impacts, reduced anxiety.	Observations of clinical evolution / 2C / B.
Berberian et al.⁽²⁹29 Berberian M, Walker MS, Kaimal G. 'Master my demons': art therapy montage paintings by active-duty military service members with traumatic brain injury and post-traumatic stress. Med Humanit. 2019;45(4):353-60. doi: http://dx.doi.org/10.1136/medhum-2018-011493 http://dx.doi.org/10.1136/medhum-2018-01... ⁾/ USA	Occupational therapy using sports (surfing) and narrative sessions with military war veterans (n=14). Weekly 4-hour sessions for 5 weeks.	Reduction in PTSD symptom scores after 5 weeks; reduction of depressive symptoms.	Cohort study / 2B / B.
Rogers et al.⁽³⁰30 Rogers CM, Mallinson T, Peppers D. High-intensity sports for posttraumatic stress disorder and depression: feasibility study of ocean therapy with veterans of operation enduring freedom and operation Iraqi freedom. Am J Occup Ther. 2014;68(4):395-404. doi: http://dx.doi.org/10.5014/ajot.2014.011221 http://dx.doi.org/10.5014/ajot.2014.0112... ⁾/ USA, Australia, Israel, Croatia, England	Sports with military war veterans (total n=4,013). Varied duration, according to the study.	Reduction of stress marker neurotransmitters, increased motivation, reduction in PTSD symptom scores, stronger positive feelings.	Systematic review with no meta-analysis / 2A / B.
Whitworth, Ciccolo⁽³¹31 Whitworth JW, Ciccolo JT. Exercise and post-traumatic stress disorder in military veterans: a systematic review. Mil Med. 2016; 181:953960. doi: http://dx.doi.org/10.7205/MILMED-D-15-00488 http://dx.doi.org/10.7205/MILMED-D-15-00... ⁾/ Vietnam, USA	Mind-body interventions (stress reduction based on mindfulness, in-person and telehealth mind-body therapy and yoga) with military war veterans (total n=479). Sessions varied between weekly 90-minute sessions for 2 weeks, and weekly 90-minute sessions for 12 weeks.	Reduction in PTSD symptom scores with follow-up assessment.	Systematic review with no meta-analysis / 2A / B.
Cushing, Braun⁽³²32 Cushing RE, Braun KL. Mind-body therapy for military veterans with post-traumatic stress disorder: a systematic review. J Altern Complement Med. 2018;24(2):106-14. doi: http://dx.doi.org/10.1089/acm.2017.0176 http://dx.doi.org/10.1089/acm.2017.0176... ⁾/ USA	Transcendental meditation with military personnel (n=74). Group and individual sessions of 1.5 to 2 hours, 5 days a week, for 3 months (at least).	Reduction in the use of psychotropic drugs, reduction in PTSD symptom scores.	Cohort study / 2B / B.
Barnes et al.⁽³³33 Barnes VA, Monto A, Williams JJ, Rigg JL. Impact of transcendental meditation on psychotropic medication use among active duty military service members with anxiety and PTSD. Mil Med. 2016;181:56-63. doi: http://dx.doi.org/10.7205/MILMED-D-14-00333 http://dx.doi.org/10.7205/MILMED-D-14-00... ⁾/ USA	Mindfulness-based stress reduction with military war veterans (n=8). Weekly group sessions for 8 weeks.	Reduction in PTSD symptom scores.	Observations of clinical evolution / 2C / B.
Bhatnagar et al.⁽³⁴34 Bhatnagar R, Phelps L, Rietz K, Juergens T, Russell D, Miller N, et al. The effects of mindfulness training on post-traumatic stress disorder symptoms and heart rate variability in combat veterans. J Altern Complement Med. 2013;19(11):860-1. doi: http://dx.doi.org/10.1089/acm.2012.0602 http://dx.doi.org/10.1089/acm.2012.0602... ⁾/ USA	Transcendental meditation versus prolonged exposure therapy with military war veterans (n=203). Weekly group and individual sessions for 12 weeks.	Reduction in similar PTSD symptom scores in both interventions, making transcendental meditation a therapeutic alternative.	Randomized controlled clinical trial / 1B / A.
Nidich et al.⁽³⁵35 Nidich PS, Mills PJ, Rainforth M, Heppner P, Schneider PRH, Rosenthal PNER, et al. Non-trauma-focused meditation versus exposure therapy in veterans with post-traumatic stress disorder: a randomised controlled trial. Lancet Psychiat. 2018;5(12):975-86. doi: http://dx.doi.org/10.1016/S2215-0366(18)30384-5 http://dx.doi.org/10.1016/S2215-0366(18)... ⁾/ USA	Horticultural therapy with military war veterans (n=49). Supervised sessions of up to 5 hours a day, for 3 weeks.	Very small reduction in stress levels and PTSD symptom scores.	Randomized clinical trial / 2B / B.
Detweiler et al.⁽³⁶36 Detweiler MB, Self JA, Lane S, Spencer L, Lutgens B, Kim DY, et al. Horticultural therapy: a pilot study on modulating cortisol levels and indices of substance craving, posttraumatic stress disorder, depression, and quality of life in veterans. Altern Ther Health Med. 2015;21(4):36-41. Available from: https://pubmed.ncbi.nlm.nih.gov/26030115/ https://pubmed.ncbi.nlm.nih.gov/26030115... ⁾/ Australia	Animal-assisted therapy using service dogs with military personnel (n=7).	Increased sense of security, reduced isolation, reduced anxiety, improved sleep, better control of anger, reduced use of medications.	Case report / 4 / C
McLaughlin, Hamilton⁽³⁷37 McLaughlin K, Hamilton AL. Exploring the influence of service dogs on participation in daily occupations by veterans with PTSD: A pilot study. Aust Occup Ther J. 2019;66:648-55. doi: http://dx.doi.org/10.1111/1440-1630.12606 http://dx.doi.org/10.1111/1440-1630.1260... ⁾/ USA	Animal-assisted therapy, through interaction with pinnipeds (seals) and military veteran personnel (n=4). Three sessions of 1 hour each, with interactions showing how to take care of and treat the animals.	Reduction in PTSD symptom scores.	Case report / 4 / C.
Wortman et al.⁽³⁸38 Wortman RA, Vallone T, Karnes M, Walawander C, Daly D, Fox-Garrity B. Pinnipeds and PTSD: an analysis of a human-animal interaction case study program for a veteran. Occup Ther Int. 2018;2018:2686728. doi: http://dx.doi.org/10.1155/2018/2686728 http://dx.doi.org/10.1155/2018/2686728... ⁾/ USA	Yoga practice with military veteran personnel (n=25); 22 hours of group yoga practice for 5 days, followed by weekly 2-hour group sessions for 5 months.	Reduction in PTSD symptom scores, with 6-month follow-up.	Randomized controlled clinical trial / 1B / A.
Carter et al.⁽³⁹39 Carter JJ, Gerbarg PL, Brown R, Ware RS, D'Ambrosio C, Anand L, et al. Multi-component yoga breath program for Vietnam veteran post traumatic stress disorder: randomized controlled trial. Trauma Stress Disor Treat. 2013;2:1-10. doi: http://dx.doi.org/10.4172/2324-8947.1000108 http://dx.doi.org/10.4172/2324-8947.1000... ⁾/ USA	Mindfulness-based stretching and deep breathing exercise (MBX) with nurses (n=29); 16 weekly 60-minute sessions.	Reduction in serum cortisol levels associated with reduction in PTSD symptom scores.	Randomized controlled clinical trial / 1B / A.

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[1] Corresponding author: Jessica Cristhyane Peixoto Nascimento BR 101, s/n - Lagoa Nova CEP 59070-405 - Natal, RN, Brazil jessicacristhy@gmail.com