Background: Face-to-face psychological treatments have difficulty meeting today’s growing mental health needs. For the highly prevalent posttraumatic stress (PTS) conditions, accumulating evidence suggests that writing therapy may constitute an efficient treatment modality, especially when administered through the Internet. We therefore conducted a meta-analysis to investigate the efficacy of writing therapies for PTS and comorbid depressive symptoms. Methods: The literature was searched using several structured and unstructured strategies, including key word searches of the PubMed, Web of Science, PsycINFO, and PILOTS databases. Six studies met eligibility criteria and were included in the analyses. These studies included a total of 633 participants, of which 304 were assigned to writing therapy. Results: Across 5 direct comparisons of writing therapy to waiting-list control, writing therapy resulted in significant and substantial short-term reductions in PTS and comorbid depressive symptoms. There was no difference in efficacy between writing therapy and trauma-focused cognitive behavioral therapy, but we caution that this finding was based on only 2 direct comparisons. Conclusions: Writing therapy is an evidence-based treatment for PTS, and constitutes a useful treatment alternative for patients who do not respond to other evidence-based treatments. Internet adaptations of writing therapy for PTS may be especially useful for reaching trauma survivors in need of evidence-based mental health care who live in remote areas or who prefer to retain their anonymity.

Kazdin AE, Blase SL: Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspect Psychol Sci 2011;6:21–37.
Bisson J, Andrew M: Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2007;3:CD003388.
Benish SG, Imel ZE, Wampold BE: The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: a meta-analysis of direct comparisons. Clin Psychol Rev 2008;28:746–758.
Frattaroli J: Experimental disclosure and its moderators: a meta-analysis. Psychol Bull 2006;132:823–865.
L’Abate L: The use of writing in psychotherapy. Am J Psychother 1991;45:87–98.
Esterling BA, L’Abate L, Murray EJ, Pennebaker JW: Empirical foundations for writing in prevention and psychotherapy: mental and physical health outcomes. Clin Psychol Rev 1999;19:79–96.
Silverman WK, Ortiz CD, Viswesvaran C, Burns BJ, Kolko DJ, Putnam FW, Amaya-Jackson L: Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events. J Clin Child Adolesc Psychol 2008;37:156–183.
Smyth JM: Written emotional expression: effect sizes, outcome types and moderating variables. J Consult Clin Psychol 1998;66:174–184.
Van Emmerik AAP, Kamphuis JH, Hulsbosch AM, Emmelkamp PMG: Single session debriefing after psychological trauma: a meta-analysis. Lancet 2002;360:766–771.
Kessler RC, Berglund P, Demler O, Jin R, Walters EE: Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry 2005;62:593–602.
Cohen BE, Gima K, Bertenthal D, Kim S, Marmar CR, Seal KH: Mental health diagnoses and utilization of VA non-mental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med 2010;25:18–24.
Milliken CS, Auchterlonie JL, Hoge CW: Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA 2007;298:2141–2148.
Polusny MA, Kehle SM, Nelson NW, Erbes CR, Arbisi PA, Thuras P: Longitudinal effects of mild traumatic brain injury and posttraumatic stress disorder comorbidity on postdeployment outcomes in National Guard soldiers deployed to Iraq. Arch Gen Psychiatry 2011;68:79–89.
Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C: Bringing the war back home – Mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med 2007;167:476–482.
Smith TC, Ryan MAK, Wingard DL, Slymen DJ, Sallis JF, Kritz-Silverstein D: New onset and persistent symptoms of post-traumatic stress disorder self-reported after deployment and combat exposures: prospective population based US military cohort study. BMJ 2008;336:366–371.
Sundin J, Fear NT, Iversen A, Rona RJ, Wessely S: PTSD after deployment to Iraq: conflicting rates, conflicting claims. Psychol Med 2010;40:367–382.
Ponniah K, Hollon SD: Empirically supported psychological treatments for acute stress disorder and posttraumatic stress disorder: a review. Depress Anxiety 2009;26:1086–1109.
Pennebaker JW: Putting stress into words: health, linguistic, and therapeutic implications. Behav Res Ther 1993;31:539–548.
Rude SS, Gortner EM, Pennebaker JW: Language use of depressed and depression-vulnerable college students. Cogn Emot 2004;18:1121–1133.
Sobel AA, Resick PA, Rabalais AE: The effect of cognitive processing therapy on cognitions: impact statement coding. J Trauma Stress 2009;22:205–211.
Molendijk ML, Bamelis L, Emmerik AAP van, Arntz A, Haringsma R, Spinhoven P: Word use of outpatients with a personality disorder and concurrent or previous major depressive disorder. Behav Res Ther 2010;48:44–51.
Van Emmerik AAP, Kamphuis JH, Emmelkamp PMG: Treating acute stress disorder and posttraumatic stress disorder with cognitive behavioral therapy or structured writing therapy: a randomized controlled trial. Psychother Psychosom 2008;77:93–100.
Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB: Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52:1048–1060.
Orsillo SM, Weathers FW, Litz BT, Steinberg HR, Huska JA, Keane TM: Current and lifetime psychiatric disorders among veterans with war zone-related posttraumatic stress disorder. J Nerv Ment Dis 1996;184:307–313.
Shadish WR, Sweeney RB: Mediators and moderators in meta-analysis: there’s a reason we don’t let dodo birds tell us which psychotherapies should have prizes. J Consult Clin Psychol 1991;59:883–893.
Spielmans GI, Pasek LF, McFall JP: What are the active ingredients in cognitive and behavioral psychotherapy for anxious and depressed children? A meta-analytic review. Clin Psychol Rev 2007;27:642–654.
Fava GA: Statistical alchemy for drug treatment of generalized anxiety disorder: A commentary on the meta-analysis by Baldwin et al. [BMJ 2011;342:d1199]. Psychother Psychosom 2011;80:261–263.
Wampold BE, Mondin GW, Moody M, Stich F, Benson K, Ahn H: A meta-analysis of outcome studies comparing bona fide psychotherapies: empirically, ‘all must have prizes’. Psychol Bull 1997;122:203–215.
Lange A, Van de Ven JP, Schrieken B, Emmelkamp PMG: Interapy. Treatment of posttraumatic stress through the Internet: a controlled trial. J Behav Ther Exp Psychiatry 2001;32:73–90.
Resick PA, Galovski TE, Uhlmansiek M, Scher CD, Clum GA, Young-Xu Y: A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. J Consult Clin Psychol 2008;76:243–258.
Lange A, Rietdijk D, Hudcovicova M, Van de Ven JP, Schrieken B, Emmelkamp PMG: Interapy: a controlled randomized trial of the standardized treatment of posttraumatic stress through the Internet. J Consult Clin Psychol 2003;71:901–909.
Lepore SJ, Smyth JM: The Writing Cure: How Expressive Writing Promotes Health and Emotional Well-Being. Washington, American Psychological Association, 2002.
Knaevelsrud C, Maercker A: Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial. BMC Psychiatry 2007;7:13.
Lange A, Ruwaard J: Ethical dilemmas in online research and treatment of sexually abused adolescents. J Med Internet Res 2010;12:e58.
Cooper H, Hedges L: The Handbook of Research Synthesis. New York, Russell Sage Foundation, 1994.
Rosenthal R: Writing meta-analytic reviews. Psychol Bull 1995;118:183–192.
Duval S, Tweedie R: A nonparametric ‘trim and fill’ method of accounting for publication bias in meta-analysis. J Am Stat Assoc 2000;95:89–99.
Duval SJ, Tweedie RL: Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000;56:455–463.
Resick PA, Schnicke MK: Cognitive Processing Therapy for Rape Victims: A Treatment Manual. Newbury Park, Sage, 1993.
Bryant RA, Moulds ML, Guthrie RM, Dang ST, Nixon RDV: Imaginal exposure alone and imaginal exposure with cognitive restructuring in treatment of posttraumatic stress disorder. J Consult Clin Psychol 2003;71:706–712.
Foa EB, Rothbaum BO, Riggs DS, Murdock TB: Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling. J Consult Clin Psychol 1991;59:715–723.
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.
Brewin CR, Andrews B, Valentine JD: Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol 2000;68:748–766.
Van Emmerik AAP, Kamphuis JH, Noordhof A, Emmelkamp PMG: Catch me if you can: do the Five-Factor Model personality traits moderate dropout and acute treatment response in post-traumatic stress disorder patients? Psychother Psychosom 2011;80:386–388.
Minnen A van, Arntz A, Keijsers GP: Prolonged exposure in patients with chronic PTSD: predictors of treatment outcome and dropout. Behav Res Ther 2002;40:439–457.
Arfken CL, Balon R: Declining participation in research studies. Psychother Psychosom 2011;80:325–328.
Higgins JPT, Thompson SG, Deeks JJ, Altman DG: Measuring inconsistency in meta-analyses. BMJ 2003;327:557–560.
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