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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

Access to therapy for people with post-traumatic stress disorder (PTSD) is limited. A study assessed an online version of cognitive behavioural therapy (CBT) for people with the condition. In those with mild-to-moderate PTSD, the online approach was as effective as, and cheaper than, the same therapy given face-to-face.

PTSD is a mental health condition triggered by frightening or distressing events. CBT with a trauma focus (CBT-TF) is a talking therapy that can help people with PTSD come to terms with a traumatic event. This therapy, given face-to-face, is recommended as a first-line treatment in the UK. But waiting lists can be up to a year.

Researchers explored whether CBT-TF, provided online and with support from a therapist, is effective. They compared it with face-to-face CBT-TF in people with mild-to-moderate PTSD.

People who received online CBT-TF benefitted as much as those who received face-to-face therapy. They appreciated the flexibility that online therapy provided. But some said they would have preferred the longer face-to-face sessions. The researchers say supported online therapy can provide treatment sooner than face-to-face therapy, but it is not appropriate for everyone.

For more information about PTSD, visit the NHS website.

The issue: long waiting times for PTSD treatment

PTSD may develop after events involving actual or threatened death, serious injury or sexual violence. About 1 in 3 people who have an extremely traumatic experience go on to develop PTSD. They may relive the event through nightmares and flashbacks; they may feel isolated, irritable and have problems sleeping. Symptoms can last for many years if not treated and the condition is linked with poor physical and mental health.

Face-to-face CBT-TF is the main treatment recommended in UK guidelines. It is a talking therapy which aims to help people come to terms with the traumatic event.

Waiting lists for therapy are long (sometimes a year or more) because of the lack of professionals trained and available to deliver it. Supported online therapy requires less time from trained professionals and could therefore allow more people to receive treatment. It might also overcome any reluctance people feel to attending face-to-face sessions.  

Researchers wanted to see if CBT-TF was as successful delivered online (via desktop or smartphone) as face-to-face sessions for people with PTSD.

What's new?

The UK study included 196 people with mild-to-moderate PTSD. Most (92%) were White. Half received supported online CBT-TF (an 8-step online programme, with up to 3 hours’ contact with a therapist, plus 4 brief telephone or email check-ups). The other half received up to 12 face-to-face CBT-TF sessions each lasting 60 to 90 minutes.

All participants had the severity of their PTSD assessed at the start of the study, 16 weeks later (at the end of treatment) and again at 1 year.

The study found:

  • PTSD symptoms improved equally after online or face-to-face treatment at 16 weeks; there was no difference between the two therapies
  • symptom improvements were sustained up to 1 year in both groups
  • online therapy was cheaper to deliver (£277 per person) than face-to-face sessions (£729 per person).

Online sessions were generally acceptable and drop-out rates were low (10%).

Researchers asked 19 participants and 10 therapists about their experience during the trial. People who received online therapy appreciated the flexibility it offered. One said: “When you go to an appointment you usually have to put aside like two/three hours. But it was with a phone call, you can do the phone call and then carry on with your day.” Some people felt they had limited connection with and support from their therapist and that treatment was too short.

Some therapists felt online therapy was a good option for people who did not want traditional face-to-face therapy: “… it got easier with… each participant that I went through it with… but the programme itself was so well designed… that… it didn't really require much heavy lifting from me.” They said that people with complex symptoms might need more sessions.

Why is this important?

In this study, people with mild-to-moderate PTSD benefitted from therapist-supported online therapy as much as from face-to-face sessions. An online course was cheaper than face-to-face therapy.

Therapist-supported online therapy takes up less therapist time than face-to-face therapy. This frees up therapists to treat people with more complex or severe symptoms. Online therapy may be available to people sooner, and is more flexible than face-to-face sessions; it can accommodate their work and childcare commitments. It might also be more acceptable to people with PTSD who struggle to leave their homes.

The online therapy used in this study was co-designed with people with PTSD to ensure they found it acceptable.

Most participants in the study were White, and all had mild-to-moderate PTSD. Further research is needed to assess online CBT-TF in people of different ethnicities, and among those with more severe PTSD.

What’s next?

Supported online CBT-TF is now being offered by all 7 health boards in Wales. The authors have presented their research to mental health commissioners across England and are discussing it with digital mental health services in Scotland. The intervention is being formally assessed by the National Institute for Health and Care Excellence (NICE).

The pandemic led to a shift towards digital therapy, but online approaches are not suitable for everyone. More research could explore whether people with complex PTSD, or those who had specific trauma experiences, still need face-to-face therapy. Further research could also consider how much training and supervision less qualified therapists would need, to deliver the online programme.

You may be interested to read

This Alert is based on: Bisson JI, and others. Guided, internet based, cognitive behavioural therapy for post-traumatic stress disorder: pragmatic, multicentre, randomised controlled non-inferiority trial (RAPID). British Medical Journal 2022;377:e069405.

A demonstration video of the SPRING programme.

A national Welsh initiative, Traumatic Stress Wales, that aims to improve the health and wellbeing of people in Wales living with PTSD or who are at risk of developing PTSD.

The National Centre for Mental Health brings together world-leading researchers from Cardiff, Swansea and Bangor universities to learn more about the causes of mental health problems.

Further work from the same research group: Bisson JI, and others. Pragmatic randomised controlled trial of guided self-help versus individual cognitive behavioural therapy with a trauma focus for post-traumatic stress disorder (RAPID). Health Technology Assessment 2023; 27(26).

Funding: This project was funded by the UK National Institute for Health Research Health Technology Assessment (NIHR HTA) programme.

Conflicts of Interest: The online CBT-TF used in this study (SPRING programme) was developed, and is owned, by Cardiff University. If commercialised, Cardiff University would benefit, as would several of the authors. A full declaration is available on the original paper.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.

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