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Accelerated Resolution Therapy (ART) for the treatment of posttraumatic stress disorder in adults: A systematic review [1]
['David Paul Storey', 'Department Of Psychology', 'Memorial University Of Newfoundland', 'St. John S', 'Nl', 'Memorial University Of Newfoundland Behavioural Medicine Centre', 'Mun-Bmc', 'Emily Claire Shaw Marriott', 'Joshua A. Rash', 'Centre For Health Policy']
Date: 2024-09
Accelerated Resolution Therapy (ART), developed in 2008, uses techniques such as rapid eye movement, in vivo exposure, and image rescripting to recondition stressful memories, and reduce physical and emotional reactions to traumatic memories. There is considerable interest in evidence-based treatments for post-traumatic stress disorder (PTSD). This is the first systematic review examining the efficacy of ART for the treatment of PTSD among adults. We searched MEDLINE, PsycINFO, Embase, CINAHL, Scopus, trial registries, and government and private websites for citations published before October 2023. Studies that reported on the effect of ART for PTSD among adults were included. Meta-analyses could not be undertaken due to heterogeneity in study designs and an insufficient number of studies with a low risk of bias. Risk of bias was assessed, and findings synthesized following the synthesis without meta-analysis (SWiM) guidelines. Of the 112 records screened, five studies (N enrolled = 337; N completed = 250) and six reports of studies met criteria for inclusion. Included studies reported a significant reduction in symptoms of PTSD from pre- to post-intervention, d = 1.12 to 3.28. Significant reductions were also reported in symptoms of depression, mental distress, anxiety, and sleep dysfunction. ART shows some promise as a time-efficient clinical treatment for symptoms of PTSD in adults; however, more high-quality studies are needed.
Data Availability: Data and related metadata supporting the findings in this review can be found in the OSF repository: Storey DP, Marriott ECS, Rash J. Accelerated Resolution Therapy (ART) for the treatment of posttraumatic stress disorder in adults: A systematic review [Internet]. OSF; 2024. Available from: osf.io/9wh4q . Data Repository Additional information not included in the main text or supplementary files can be accessed at the following link:
https://osf.io/9wh4q/ . Information provided here includes: a) table of all data extracted from the primary sources for the review; b) responses to requests for information from authors; c) forest plot calculations; d) effect size calculations for Kip et al., 2015; standard deviation calculations for Rossiter et al., 2017; and e) a copy of Witt’s 2019 dissertation.
Copyright: © 2024 Storey et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This systematic review will contribute to the literature by identifying, summarizing, and evaluating previous research that has examined the use of ART for PTSD. The aim of this review is to assess the risk of bias among studies reporting on ART and evaluate the efficacy of ART for symptoms of PTSD among adults (18 years or older) as compared to treatment as usual, pharmacotherapy, or another psychotherapy.
ART integrates aspects from various forms of psychotherapy, and uses techniques such as rapid eye movement, in vivo exposure, and image rescripting to recondition stressful memories, and reduce the physical and emotional reactions to traumatic memories [ 10 ]. The client remains in control during the sessions and does not need to talk about their traumatic experiences with the therapist to achieve recovery. It has been claimed that ART is often able to resolve a client’s presenting concern in one to five sessions and that it is also beneficial for the treatment of mental health problems that are commonly associated with PTSD, such as anxiety and depression [ 11 ].
There are three interventions strongly recommended for the treatment of PTSD: trauma focused cognitive behavioural therapy (CBT), cognitive processing therapy (CPT), and prolonged exposure (PE) [ 7 ]. Trauma focused CBT is a 12–16 session present focused treatment that aims to understand how a client’s current thoughts, feelings, and behaviors around a trauma are maintaining their difficulties, and then works with the client to help them get ‘unstuck’ by applying principles from both cognitive and behavioral psychology (e.g., challenging unhelpful beliefs, activity scheduling, etc.). CPT for PTSD is a 12-session treatment which focuses initially on why a trauma occurred and then emphasizes identifying, challenging, and then modifying unhelpful beliefs related to the trauma through the use of progressive worksheets. PE for PTSD is an 8–15 session treatment consisting of imaginal exposure—recounting the traumatic memory and processing the experience—and in vivo exposure—repeatedly confronting trauma-related stimuli that are now safe but were previously avoided. Additional interventions that have some support are eye movement desensitization and reprocessing (EMDR) therapy and pharmacotherapy, such as sertraline, paroxetine, fluoxetine, and venlafaxine [ 8 ]. EMDR is a 6–12 session exposure-based therapy that pairs rapid eye movements—which proponents claim facilitate processing and integration—with cognitive processing of traumatic memories. One treatment for PTSD currently pending re-evaluation for strength of research support—based on the Tolin et al., 2015 criteria [ 9 ] adopted by the American Psychological Association’s Division 12: Society of Clinical Psychology—is accelerated resolution therapy (ART), a brief therapy that was developed in 2008 and introduced in the published literature in 2012.
While estimates vary, posttraumatic stress disorder (PTSD) is a prevalent and debilitating disorder. In a systematic review of the literature on PTSD in primary care settings globally (k = 27, N = 24,998), Greene, Neria [ 1 ] reported that prevalence rates ranged between 2% and 39% with significant heterogeneity in estimates explained by the level of trauma exposure among samples. In a systematic review of 27 studies (N = 30,878) reporting on the prevalence of mental health conditions among ambulance personnel, a population regularly exposed to trauma, Petrie, Milligan-Saville [ 2 ] estimated the prevalence rate of PTSD at 11% worldwide. According to the U.S. Department of Veterans Affairs National Center for PTSD [ 3 ] about 6% of the U.S. general population will have PTSD at some point in their lives and in any given year about 5% of the U.S. general population has active PTSD symptoms. In the general population PTSD is more common in women (8%) than men (4%), largely due to women’s increased exposure to sexual violence [ 3 ]. In military and veteran populations rates of PTSD are higher for both men and women. Mota, Tsai [ 4 ] examined the prevalence and clinical correlates of subthreshold PTSD on a sample of 1,484 U.S. military veterans who participated in the National Health and Resilience in Veterans Study (NHRVS). They observed that approximately one in three U.S. veterans experience clinically significant PTSD symptoms in their lifetime, and that subthreshold PTSD is associated with an elevated burden of comorbid psychiatric disorders, such as depression and anxiety. The presence of PTSD or posttraumatic stress symptoms (PTSS) is associated with greater frequency and severity of pain, cardio-respiratory symptoms, and gastrointestinal symptoms, as well as poor health related quality of life and poor work and family functioning [ 5 , 6 ].
Methods
This review was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 checklist [12], which can be found in S1 Appendix. The protocol for this study was published as a preprint on PsyArXiv [13], and can be viewed at the following address:
https://psyarxiv.com/npqg3. This review was not registered.
Information sources & search strategy The search strategy was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions [14]. In October 2022, we consulted with a qualified research librarian to develop the search strategy and identified five electronic databases to search: MEDLINE, PsycINFO, EMBASE, CINAHL, and Scopus. The following trial registers were also searched: Cochrane Central Register of Controlled Trials (CENTRAL), US government website of clinical trials (ClinicalTrials.gov), and the WHO International Clinical Trials Registry Platform (ICTRP). Forward citation searches were conducted on applicable databases. Reference lists of relevant publications were hand-searched to identify additional publications (i.e., backward citation searches). Additional literature searches were conducted on the U.S. Department of Veterans Affairs website,
https://www.va.gov/; the APA Division 12 webpage for psychological treatments of PTSD,
https://div12.org/diagnosis/posttraumatic-stress-disorder/; and the official ART publications webpage,
https://acceleratedresolutiontherapy.com/evidence-based/. Search terms were developed using controlled and uncontrolled vocabulary. All text searches were conducted with no limits placed on year of publication or publication status. Our search strategy was reviewed by a second research librarian using the Peer Review of Electronic Search Strategies (PRESS) checklist [15]. The initial search was completed during the fourth week of October 2022, and updated on 14 October 2023; search terms used can be found in S2 Appendix.
Eligibility criteria A wide net was cast given the relative paucity of studies on ART at this time. The PICOS—Population, Intervention, Comparison, Outcome, Study design—approach [16] was used to structure the eligibility criteria for this review, with the addition of ‘length of follow-up’. The population of interest was adults 18 years of age or older—military or civilian—who met a clinical cut-off score for PTSD on a validated screening measure (e.g., PCL-5). The psychological intervention of interest was ART delivered in any setting (e.g., private practice, hospital, residential treatment centre, military deployment, etc.) by a qualified mental health professional with comparison to an active (e.g., CBT, pharmacotherapy, treatment as usual), or inactive control (e.g., wait-list) group. Intervention studies that did not include a control group (e.g., cohort studies, case series, feasibility studies) were also eligible. The primary outcome of interest was change in PTSD symptom severity from baseline to post intervention as measured by a validated scale of PTSD symptomatology. Secondary outcomes of interest included change in symptoms of psychological distress, depression, anxiety, and sleep quality. Additional outcomes of interest included treatment engagement and retention as measured by the number of sessions attended and the participant attrition rate prior to the end of treatment and prior to the last follow-up. Reports of harms possibly or probably associated with the intervention were also of interest. A wide range of study designs were considered including randomized controlled trials (RCTs), non-randomized trials, cohort studies, case-control studies, case series, and feasibility studies. Studies were excluded if they: a) did not utilize a quantitative design; b) were not primary studies or did not report on primary studies; c) were not peer-reviewed; and d) were in a language other than English with no English translation available. No restrictions were placed on length of follow-up.
Screening & data extraction Duplicates were removed and remaining citations were uploaded to Covidence for screening. Two review authors, DS and EM, independently reviewed titles and abstracts of uploaded records and discussed discrepancies until consensus was reached. Records that passed title and abstract screening underwent an independent full-text review by the same authors, with disagreements resolved through discussion until consensus was reached. We designed a data extraction form in Covidence based on our PICOS statement which was piloted by EM on one study and independently verified by DS on a second study. Both EM and DS independently extracted data from eligible studies. Extracted data were compared and discrepancies resolved through discussion. Corresponding authors were contacted between October and November 2023 to provide further details in cases where data was missing, or important information was not reported. Where missing data could be calculated based on available data, this was done in accordance with the methods laid out in the forthcoming synthesis methods section. Based on the recommendations of Mullan, Flynn [17], details on the missing information requested, author contact, and author response are presented in S3 Appendix. Essential data were extracted from each study including: a) author, year, and source of publication; b) characteristics of participants (e.g., age, gender, race, military or civilian status); c) number of participants enrolled and number of participants who completed treatment; d) the inclusion criteria used; e) the details of the ART intervention (e.g., number and length of sessions, who delivered them, deviations from the treatment protocol); f) the comparison used (if applicable); g) primary and secondary outcome measures; h) research design and features (e.g., sampling mechanism, treatment assignment mechanism, non-response, length of follow-up); i) treatment setting; j) adverse events; and k) the funding source. Outcomes of interest were also extracted from each study at each timepoint (i.e., pre-intervention, post-intervention, follow-up) to allow for calculation of change over time, including: a) PTSD symptom severity; b) severity of psychological distress; c) symptoms of depression; d) symptoms of anxiety; e) sleep quality; f) treatment engagement and retention as measured by the average or modal number of ART sessions attended; g) participant attrition prior to the end of treatment and prior to last follow-up; and h) reports of harms likely associated with the intervention.
Risk of bias assessment Risk of bias was assessed using the National Institute of Health (NIH) Study Quality Assessment Tools to evaluate methodological limitations, including sources of bias, confounding, study power, and other factors [18]. The tools are designed to facilitate critical appraisal of a study’s risk of bias and culminate in a global rating of ‘good’, ‘fair’, or ‘poor’ quality. A ‘good’ study is considered to have strong internal validity and a low risk of bias. A ‘fair’ study is considered to have moderate internal validity along with various strengths and weaknesses, equating to a moderate risk of bias. A ‘poor’ study is considered to have poor internal validity and hence high risk of bias. Two review authors, EM and DS independently applied the tool to each included study and recorded supporting information and justifications for judgments of risk of bias. Discrepancies were resolved by discussion to reach consensus. The quality assessment checklists for each of the five primary studies can be found in S4 Appendix.
Effect measures The efficacy of ART on continuous outcome measures was compared across studies using standardized mean difference (SMD) effect sizes and their 95% confidence intervals (CIs). A small effect size was considered as 0.2–0.49, a moderate effect size as 0.5–0.79, and a large effect size as greater than 0.8 [19]. Intention to treat (ITT) effect sizes were favoured for inclusion over completer effect sizes where a study reported both.
Synthesis methods Meta-analyses could not be undertaken due to heterogeneity in study designs and an insufficient number of studies with a low risk of bias. Narrative synthesis was used to describe results of individual studies and followed the synthesis without meta-analysis (SWiM) guidelines [20]. This synthesis was formatted around population features, ART intervention details, comparisons used, outcomes, study design, and treatment context. Summary of findings tables have been structured using the PICOS approach [16] within which primary studies and reports of studies are ordered by study design category (i.e., RCT vs observational) and for primary studies, quality rating. A forest plot was generated without a pooled estimate to present primary studies grouped by whether they employed a randomized-control or observational design, following methods laid out in Chapter 12 of the Cochrane Handbook [21]. Studies were ordered within the forest plot by descending quality rating as assessed by NIH Study Quality Assessment Tools [18]. This presentation was selected to facilitate examination of heterogeneity in reported effects. Sub-group analysis could not be conducted on men versus women nor on military personnel/veterans versus civilians, due to an insufficient number of included studies. Only the effect of ART on PTSD symptom severity from pre- to post-intervention could be displayed due to a limited number of studies employing a control group, heterogeneity in the types of control groups used, limited reporting of summary statistics for secondary outcome measures, and heterogeneity in follow-up periods. SMDs were calculated for the effect of ART on PTSD symptoms severity from pre- to post-intervention. In the case of randomized-control designs, mean gain scores, pre and post standard deviations, and pre-post correlations were extracted to calculate the SMD with 95% confidence intervals using formulae from Lipsey and Wilson [22]. In the case of non-randomized designs, dependent samples t-tests were conducted to calculate the standardized mean difference with 95% confidence intervals. Formulae from Chapter 6 of the Cochrane Handbook [23] were used to calculate the standard error, and from that the standard deviation in cases where standard deviations were not reported, but the mean difference and t-score were. A medium association, r = .30, was used when studies did not report the correlation between pre and post intervention, with sensitivity tests conducted using r = .50 and r = 10 to ensure results were not appreciably different. In one case it was necessary to combine means and standard deviations from two groups (i.e., homeless and housed veterans who were reported not to differ significantly, p = .24) using the formulae and , respectively.
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