Remission from post-traumatic stress disorder in adults: A systematic review and meta-analysis of long term outcome studies

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Highlights

  • We conducted a meta-analysis on spontaneous long-term remission from PTSD.

  • Remission was defined as reporting PTSD at baseline and not after at least ten months.

  • 42 studies and 81,642 participants were included.

  • Overall, 44.0% of participants remitted from PTSD after a mean of 40 months.

Abstract

Posttraumatic stress disorder (PTSD) is a frequent mental disorder associated with significant distress and high costs. We conducted the first systematic review and meta-analysis on spontaneous long-term remission rates, i. e., without specific treatment. Data sources were searches of databases, hand searches, and contact with authors. Remission estimates were obtained from observational prospective studies of PTSD without specific treatment. Remission was defined as the actual percentage of PTSD cases at baseline who are non-cases after a minimum of ten months. Forty-two studies with a total of 81,642 participants were included. The mean observation period was 40 months. Across all studies, an average of 44.0% of individuals with PTSD at baseline were non-cases at follow-up. Remission varied between 8 and 89%. In studies with the baseline within the first five months following trauma the remission rate was 51.7% as compared to 36.9% in studies with the baseline later than five months following trauma. Publications on PTSD related to natural disaster reported the highest mean of remission rate (60.0%), whereas those on PTSD related to physical disease reported the lowest mean of remission rate from PTSD (31.4%). When publications on natural disaster were used as a reference group, the only type of traumatic events to differ from natural disaster was physical disease. No other measured predictors were associated with remission from PTSD. Long-term remission from PTSD without specific treatment varies widely and is higher in studies with the baseline within five months following trauma.

Introduction

Epidemiological research indicates that most people experience at least one potentially traumatic event during their lifetime (Breslau et al., 1991, Creamer et al., 2001, Kessler et al., 1995, Perkonigg et al., 2000). In many parts of the world, individuals are exposed to large-scale traumatic events, such as wars or natural disasters (Neria et al., 2008, Priebe et al., 2010). Whilst traumatic experiences can lead to a range of mental health problems, post-traumatic stress disorder (PTSD) is the most documented disorder following trauma. The diagnostic criteria for PTSD require the onset of characteristic symptoms following exposure to a traumatic event that must be present for more than one month (American Psychiatric Association, 2000). The prevalence estimates of PTSD are high. For example, in the European and US general population the 12-month prevalence of PTSD has been estimated between 2.0 and 3.5% (Kessler et al., 2005, Wittchen et al., 2011). PTSD is associated with significant mental and physical distress (Nemeroff et al., 2006) as well as high economic burden (Kessler, 2000, Sabes-Figuera et al., 2012, Wittchen et al., 2011).

There is good empirical evidence for the moderate efficacy of trauma-focused psychological interventions (Ehlers et al., 2010) and to a lesser degree for pharmacotherapy (Stein, Ipser, & McAnda, 2009). Yet, a significant number of individuals with PTSD do not seek treatment for their complaints (Gavrilovic, Schützwohl, Fazel, & Priebe, 2005), or fail to receive treatment, e.g., when they live in areas with limited or no access to mental health services after war or natural disasters (Morina, Rushiti, Salihu, & Ford, 2010). The question arises as to how important it is to expand the provision of treatment to all those people with PTSD who are currently without treatment. This can only be assessed based on data about the long-term outcomes of PTSD without treatment. Available prospective studies on the course of PTSD indicate different trajectories in different populations. Differences across studies are presumed to occur due to the different nature of traumatic events, methodological differences, current living conditions, and psychological factors (Brewin et al., 2000, Ozer et al., 2003, Schnurr et al., 2004). There is lack of a published systematic review on the remission rate of PTSD without specific treatment. Accordingly, we conducted a systematic review and meta-analysis of prospective studies to assess the remission rate of PTSD without specific treatment. Furthermore, the study aimed at identifying variables that explain variations in remission estimates across studies.

Section snippets

Method

Observational prospective studies on the natural course of PTSD published since 1980 (i.e., since the introduction of PTSD in DSM-III) (American Psychiatric Association, 1980) were located in the following computerized bibliographic databases: PUBMED, PsycINFO, and the PILOTS database managed by the US National Center for PTSD. The following search terms were used: post-traumatic stress disorder or posttraumatic stress disorder or PTSD AND long* or prognos* or follow-up or prospect* or cohort*

Selection and inclusion of studies

The initial search identified 21.029 potential hits (see Fig. 1 for the flow diagram). The first review resulted in a total of 99 publications eligible for inclusion. After contacting authors regarding missing information related to the prevalence of PTSD at both assessment points in potentially relevant articles, 49 publications were excluded because of missing information and eight publications were identified as double publications of already included studies. A total of 42 studies were

Discussion

The meta-analysis shows that the number of participants remitting from PTSD after at least ten months varies greatly. On average nearly half of participants diagnosed with PTSD remit from this disorder after a mean of more than three years. Studies with the first assessment of PTSD within the first five months following trauma reported a higher remission rate of PTSD than those with a later first assessment of PTSD. Further, participants with PTSD in relation to physical disease reported a

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