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INTRODUCTION: While several previous meta-analyses have documented the short-term efficacy of cognitive-behavioral therapy (CBT), its long-term efficacy remains unknown. Posttraumatic stress disorder (PTSD) is a serious, debilitating, often chronic and disabling disease. OBJECTIVE: To estimate the long-term efficacy of CBT in the treatment of PTSD by assessing the maintenance of the effect after one year of follow-up. METHOD: We performed a systematic review through electronic database searches including ISI Web of Science, PubMed, PsycInfo and Pilots. We included randomized studies in which CBT was compared with a control group (waiting list or usual care) in adults with PTSD that reported at least one year of CBT follow-up. RESULTS: Our search identified 2,324 studies and 8 were selected. CBT was shown to be effective in the treatment of PTSD in the post-treatment period. Improvement in PTSD symptoms was statistically significant in relation to the control group. The improvement observed in the treatment group or single group (formed by both treatment group and control group, which was submitted to the intervention after a few weeks on the waiting list) was maintained in the follow-up. CONCLUSION: Due to the lack of control groups in the follow-up period in six of the eight studies included in this review, there is still no proper methodological basis to assert that CBT has lasting effects in the treatment of PTSD. Our study found serious methodological shortcomings and the need to fill this gap in the literature through the development of studies with robust and sophisticated designs.

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Abstract Introduction: While several previous meta-analyses have documented the short-term efficacy of cognitive-behavioral therapy (CBT), its long-term efficacy remains unknown. Posttraumatic stress disorder (PTSD) is a serious, debilitating, often chronic and disabling disease. Objective: To estimate the long-term efficacy of CBT in the treatment of PTSD by assessing the maintenance of the effect after one year of follow-up. Method: We performed a systematic review through electronic database searches including ISI Web of Science, PubMed, PsycInfo and Pilots. We included randomized studies in which CBT was compared with a control group (waiting list or usual care) in adults with PTSD that reported at least one year of CBT follow-up. Results: Our search identified 2,324 studies and 8 were selected. CBT was shown to be effective in the treatment of PTSD in the post-treatment period. Improvement in PTSD symptoms was statistically significant in relation to the control group. The improvement observed in the treatment group or single group (formed by both treatment group and control group, which was submitted to the intervention after a few weeks on the waiting list) was maintained in the follow-up. Conclusion: Due to the lack of control groups in the follow-up period in six of the eight studies included in this review, there is still no proper methodological basis to assert that CBT has lasting effects in the treatment of PTSD. Our study found serious methodological shortcomings and the need to fill this gap in the literature through the development of studies with robust and sophisticated designs.

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.

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The treatment of anxiety is on the edge of a new era of combinations of pharmacologic and psychosocial interventions. A new wave of translational research has focused on the use of pharmacological agents as psychotherapy adjuvants using neurobiological insights into the mechanism of the action of certain psychological treatments such as exposure therapy. Recently, d-cycloserine (DCS) an antibiotic used to treat tuberculosis has been applied to enhance exposure-based treatment for anxiety and has proved to be a promising, but as yet unproven intervention. The present study aimed to evaluate the efficacy of DCS in the enhancement of exposure therapy in anxiety disorders. A systematic review/meta-analysis was conducted. Electronic searches were conducted in the databases ISI-Web of Science, Pubmed and PsycINFO. We included only randomized, double-blind, placebo-controlled trials with humans, focusing on the role of DCS in enhancing the action of exposure therapy for anxiety disorders. We identified 328 references, 13 studies were included in our final sample: 4 on obsessive-compulsive disorder, 2 on panic disorder, 2 on social anxiety disorder, 2 on posttraumatic stress disorder, one on acrophobia, and 2 on snake phobia. The results of the present meta-analysis show that DCS enhances exposure therapy in the treatment of anxiety disorders (Cohen d =  -0.34; CI: -0.54 to -0.14), facilitating the specific process of extinction of fear. DCS seems to be effective when administered at a time close to the exposure therapy, at low doses and a limited number of times. DCS emerges as a potential new therapeutic approach for patients with refractory anxiety disorders that are unresponsive to the conventional treatments available. When administered correctly, DCS is a promising strategy for augmentation of CBT and could reduce health care costs, drop-out rates and bring faster relief to patients.

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BACKGROUND: Non-remission rates to pharmacotherapy for anxiety disorders are related to higher relapse rates, decreased quality of life and greater functional impairment. Here we sought to investigate the efficacy of cognitive-behavior therapy (CBT) as a next-step strategy in the treatment of patients with anxiety disorders who did not remit after a pharmacological intervention. METHOD: We carried out a systematic review in the ISI, Pubmed and PsycINFO/PsychLit databases. Studies that did not use CBT and that did not focus on resistance to drug therapy were excluded. We considered resistant patients who failed to respond (did not fully remit) to an adequate trial of pharmacotherapy and still exhibited residual symptoms of anxiety disorder. RESULTS: We identified 603 references in our survey, of which 17 were included: eight were on OCD, five on panic disorder, and four on PTSD. No studies were found on social anxiety disorder and generalized anxiety disorder. We observed a lack of standardization of terminology and of definitions of resistance, which makes comparison of results difficult. Finally, all of the identified studies showed benefits from the addition of CBT as a next-step strategy. LIMITATIONS: A limited number of randomized controlled studies were found. CONCLUSIONS: CBT seems to be a promising next-step strategy for patients with anxiety disorders who did not remit with drug-based therapies. However, further clinical trials with strong methodological designs are needed to definitely establish its efficacy in this population.

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CONTEXTO: O estabelecimento de biomarcadores relacionados à terapia cognitivo-comportamental (TCC) é uma maneira de consolidar a eficácia do tratamento de forma mais objetiva, sendo crítico para o avanço desse campo de pesquisa. OBJETIVOS: Foi realizada uma revisão sistemática de estudos que: 1) utilizaram parâmetros biológicos para verificar a eficácia da TCC no tratamento do transtorno de estresse pós-traumático (TEPT); e 2) utilizaram esses parâmetros como preditores de resposta à CBT. MÉTODOS: Foram conduzidas buscas eletrônicas nas bases PubMed/Medline, ISI/Thompson Reuters e Pilot. RESULTADOS: Doze artigos foram selecionados para esta revisão, sendo quatro deles estudos sobre predição de resposta ao tratamento. Foi observada relação entre a eficácia da TCC e modificações nesses parâmetros, sendo a resposta da frequência cardíaca à evocação de sintomas o parâmetro mais utilizado até o presente momento. Sua redução está associada à melhora nos sintomas de TEPT. Potenciais biomarcadores de predição de resposta encontrados incluem 5α-redutase, ativação da amígdala, ativação e volume do córtex cingulado anterior e frequência cardíaca. CONCLUSÃO: Apesar da escassez de estudos e das limitações metodológicas neles observadas, investigações iniciais sugerem que os biomarcadores da TCC em pacientes com TEPT poderão ser úteis para o monitoramento mais objetivo dos efeitos do tratamento, identificação de predição de resposta e para o desenvolvimento de estratégias mais eficazes de tratamento e prevenção do desenvolvimento de TEPT.

BACKGROUND: The establishment of biomarkers related to cognitive-behavior therapy (CBT) is a method to objectively consolidate treatment efficacy, which is critical to advancing the field. OBJECTIVES: We systematically reviewed studies that used biological parameters to assess the efficacy of CBT for the treatment of post-traumatic stress disorder (PTSD) and studies that used these parameters as predictors of response to CBT. METHODS: Computerized literature searches were conducted in PubMed/Medline, ISI/Thompson Reuters, and Pilot databases using both thesaurus and free-word search terms. RESULTS: 12 articles met the selection criteria. 4 of them were response predictors studies. A relationship was found between CBT efficacy and changes in the measured parameters, with heart rate responses to symptom provocation being the parameter most often studied. The reduction in heart rate was associated with an improvement in PTSD symptoms. The potential biomarkers of response predictions found included 5α-reductase, amygdala activation, activation and volume of the anterior cingulate cortex, and heart rate. DISCUSSION: Despite the scarcity of studies and their methodological shortcomings, initial investigations indicate that biomarkers of CBT in PTSD patients hold promise for more objective treatment outcome monitoring, identification of response predictors, and for developing novel treatment and prevention strategies.

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