A TCC possui efeitos duradouros no tratamento do TEPT após um ano de seguimento? Revisão sistemática de ensaios clínicos randomizados

Macedo, Tânia; Barbosa, Marllon; Rodrigues, Helga; Coutinho, Evandro da Silva Freire; Figueira, Ivan; Ventura, Paula

doi:10.1590/2237-6089-2017-0153

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Trends in Psychiatry and Psychotherapy

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Sumário

Review Article • Trends Psychiatry Psychother. 40 (4) • Oct-Dec 2018 • https://doi.org/10.1590/2237-6089-2017-0153 copiar

A TCC possui efeitos duradouros no tratamento do TEPT após um ano de seguimento? Revisão sistemática de ensaios clínicos randomizados

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo

Introdução:

Várias meta-análises anteriores documentaram a eficácia a curto prazo da terapia cognitivo-comportamental (TCC). No entanto, sua eficácia a longo prazo permanece desconhecida. O transtorno de estresse pós-traumático (TEPT) é uma doença crônica grave, debilitante e incapacitante.

Objetivo:

Estimar a eficácia a longo prazo da TCC no tratamento do TEPT, avaliando a manutenção do efeito após um ano de seguimento.

Métodos:

Realizamos uma revisão sistemática através de pesquisas nas bases de dados eletrônicas ISI Web of Science, PubMed, PsycInfo e Pilots. Incluímos estudos randomizados nos quais a TCC foi comparada com um grupo controle (lista de espera ou tratamento usual) em adultos com TEPT que relataram pelo menos um ano de seguimento da TCC.

Resultados:

A pesquisa identificou 2.324 estudos e 8 foram selecionados. A TCC mostrou-se eficaz no tratamento do TEPT no período pós-tratamento. A melhora nos sintomas de TEPT foi estatisticamente significativa em relação ao grupo controle. A melhora observada no grupo de tratamento ou grupo único (formado por ambos os grupos de tratamento e controle, que foi submetido à intervenção após algumas semanas na lista de espera) foi mantida no seguimento.

Conclusão:

Devido à ausência de grupo controle no período de follow-up em 6 dos 8 estudos incluídos nesta revisão, ainda não há base metodológica adequada para afirmar que a TCC tem efeitos duradouros no tratamento do TEPT. Nosso estudo encontrou graves deficiências metodológicas e a necessidade de preencher essa lacuna na literatura através de estudos com delineamentos robustos e sofisticados.

Descritores:
Transtorno de estresse pós-traumático; terapia cognitivo-comportamental; seguimento; efeitos duradouros

Study	n at baseline, n at the end	Mean age % of women	Intervention	Control Group	Components of CBT	Protocol	Instrument	Main results
Azukai et al.¹⁴14. Asukai N, Saito A, Tsuruta N, Kishimoto J, Nishikawa T. Efficacy of exposure therapy for Japanese patients with posttraumatic stress disorder due to mixed traumatic events: a randomized controlled study. J Trauma Stress. 2010;23:744-50.	24 (PE = 12, TAU = 12) 24 (PE = 12, TAU = 12)	27.1±5.4 (PE) 31.4±8.8 (TAU)	PE	TAU	PE	8 to 15 sessions of 90 minutes 1x per week	CAPS	The intervention group had a greater reduction in PTSD symptoms than the control group after treatment (p < 0.01). The control group also showed a significant decrease in severity of PTSD symptoms after being treated with PE.
Chard¹⁵15. Chard KM. An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. J Consult Clin Psychol. 2005;73:965-71.	71 (CPT = 36, WL = 35) 55 (CPT = 28, WL = 27)	32.77±8.87 100%	CPT	WL	CPT	17 sessions of 90 min (in group) and 9 sessions (individual) of 60 min in the first 9 weeks 1 x per week	CAPS	The severity of PTSD symptoms after treatment was lower in the intervention group (p < 0.01).
Foa et al.¹⁶16. Foa EB, Dancu CV, Hembree EA, Jaycox LH, Meadows EA, Street GP. A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. J Consult Clin Psychol. 1999;67:194-200.	96 79 (PE = 23, SIT = 19, PE + SIT = 22, WL = 5)	34.9±10.6 100%	PE SIT PE + SIT	WL	CR PE SIT	9 sessions 2x per week	PSS-I	There was a reduction in the severity of PTSD symptoms in the intervention groups in relation to the waiting list (p < 0.01).
Foa et al.¹⁷17. Foa EB, Hembree EA, Cahill SP, Rauch SAM, Riggs DS, Feeny NC, et al. Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics. J Consult Clin Psychol. 2005;73:953-64.	171 (PE/CR = 74, PE = 79, WL = 26) 121 (PE/CR = 44, PE = 52, WL = 25)	31.3±9.8 100%	PE PE + CR	WL	CR PE	9 to 12 sessions of 90 to 120 min 1x per week	PSS-I	The intervention groups obtained a greater reduction in PTSD symptoms than that observed in the control group (p < 0.05).
Knaevelsrud et al.¹⁸18. Knaevelsrud C, Maercker A. Long-term effects of an internet-based treatment for posttraumatic stress. Cogn Behav Ther. 2010;39:72-7.	96 (CBT = 49, WL = 47) 87 (CBT = 41, WL = 46)	34±11.5 (CBT), 36±9.6 (WL) 84% (CBT), 96% (WL)	CBT	WL	CR PE	10 sessions (Internet) of 45 minutes 2x per week	IES-R	The severity of PTSD symptoms after treatment was lower in the intervention group (p < 0.05).
Mueser et al.19	201(CBT = 104, Brief = 97) 161(CBT = 86, Brief = 75)	42.96±10.46 (CBT), 44.52±11.60 (Brief) 70.2% (CBT), 67% (Brief)	CBT	Brief	CR	12 to 16 sessions of 60 min 1x per week	CAPS	Participants in both programs had an improvement in PTSD symptoms after treatment. The intervention group had greater improvement than the control group (p = 0.01).
Nacasch et al.²⁰20. Nacasch N, Foa EB, Huppert JD, Tzur D, Fostick L, Dinstein Y, et al. Prolonged exposure therapy for combat- and terror-related posttraumatic stress disorder: A randomized control comparison with treatment as usual. J Clin Psychiatry. 2011;72:1174-80.	30 (PE = 15, TAU = 15) 26 (PE = 13, TAU = 13)	34.8±11.4 (PE), 33.7±11.9 (TAU) 7%	PE	TAU	PE	9 to 15 sessions of 90 to 120 minutes 1x per week	PSS-I	The severity of PTSD after treatment was lower in the intervention group compared to the control group (p < 0.01).
Power et al.21	105 (EMDR = 39, PE + CR = 37, WL = 29) 72 (EMDR = 27, PE + CR = 21, WL = 24)	38.6±11. 8 (EMDR), 43.2±11.0 (PE + CR), 36.5±11.6 (WL)	E + CR EMDR	WL	CR PE	10 sessions of 90 min 1 x per week	CAPS	There were reductions in PTSD symptoms after treatment in the intervention group (p < 0.05), but no change in the control group. Both treatments were effective in relation to the control group.

Study	n at start of follow-up, n at the end of follow-up	Follow-up period	Control croup in the followup period	Main results
Azukai et al.¹⁴14. Asukai N, Saito A, Tsuruta N, Kishimoto J, Nishikawa T. Efficacy of exposure therapy for Japanese patients with posttraumatic stress disorder due to mixed traumatic events: a randomized controlled study. J Trauma Stress. 2010;23:744-50.	24 (PE = 12, TAU = 12) 19 (PE + TAU who received the intervention from the 10th week)	12 months	No (Single group formed by the intervention + control group that received the intervention from the 10th week)	The significant reduction in PTSD symptoms observed in the intervention group (and in the control group receiving the intervention) after treatment was also observed in the single group created in the follow-up period.
Chard¹⁵15. Chard KM. An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. J Consult Clin Psychol. 2005;73:965-71.	55 (CPT = 28, WL = 27) 27 (CPT + WL who received intervention from week 17)	12 months	No	Significant reductions in PTSD symptoms in the intervention group after treatment were maintained at follow-up.
Foa et al.¹⁶16. Foa EB, Dancu CV, Hembree EA, Jaycox LH, Meadows EA, Street GP. A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. J Consult Clin Psychol. 1999;67:194-200.	79 (PE = 23, SIT = 19, PE + SIT = 22, WL = 15) 46 (PE = 16, SIT = 14, PE + SIT = 16)	12 months	No	Significant reductions in PTSD symptoms after treatment in the intervention groups were maintained at follow-up.
Foa et al.¹⁷17. Foa EB, Hembree EA, Cahill SP, Rauch SAM, Riggs DS, Feeny NC, et al. Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics. J Consult Clin Psychol. 2005;73:953-64.	121 (PE/CR = 44, PE = 52, WL = 25) 53 (PE/CR = 25, PE = 28)	12 months	No	Significant reductions in post-treatment PTSD symptoms compared to the control group were maintained at follow-up.
Knaevelsrud et al.¹⁸18. Knaevelsrud C, Maercker A. Long-term effects of an internet-based treatment for posttraumatic stress. Cogn Behav Ther. 2010;39:72-7.	87 (CBT = 41, WL = 46) 34 (CBT)	18 months	No	Significant reductions in PTSD symptoms in the intervention group after treatment were maintained at follow-up.
Mueser et al.¹⁹19. Mueser KT, Gottlieb JD, Xie H, Lu W, Yanos PT, Rosenberg SD, et al. Evaluation of cognitive restructuring for post-traumatic stress disorder in people with severe mental illness. Br J Psychiatry. 2015;206:501-8.	161 (CBT = 86, Brief = 75) 156 (CBT = 83, Brief = 73)	12 months	Yes (Brief)	A significant improvement in PTSD symptoms in the intervention group compared to the control group observed in the post-treatment period remained at follow-up.
Nacasch et al.²⁰20. Nacasch N, Foa EB, Huppert JD, Tzur D, Fostick L, Dinstein Y, et al. Prolonged exposure therapy for combat- and terror-related posttraumatic stress disorder: A randomized control comparison with treatment as usual. J Clin Psychiatry. 2011;72:1174-80.	26 (PE = 13, TAU = 13) 22 (PE = 13, TAU = 9)	12 months	Yes (TAU)	There was a significant change from pre-treatment to one-year follow-up in the intervention group, but not in the control group.
Power et al.²¹21. Power K, McGoldrick T, Brown K, Buchanan R, Sharp D, Swanson V, et al. A controlled comparison of eye movement desensitization and reprocessing versus exposure plus cognitive restructuring versus waiting list in the treatment of post-traumatic stress disorder. Clin Psychol Psychother. 2002;9:299-318.	72 (EMDR = 27, PE + CR = 21, WL = 24) 39 (EMDR = 22, PE + CR = 17)	15 months	No	Significant reductions in PTSD symptoms after treatment in the intervention groups were maintained at follow-up.

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[1] Correspondence: Tânia Macedo Av. Venceslau Bras, 71, fundos 21941-901 - Rio de Janeiro, RJ - Brazil Tel.: +55 (21) 3938-5535/5536 E-mail: fmacedo.tania@gmail.com