Comparative Efficacy and Acceptability of Psychological and Virtual Reality-Based Interventions for Post-Traumatic Stress Disorder: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Background: Virtual reality exposure therapy (VRET) may support engagement in trauma-focused treatment, but its standing relative to established psychotherapies for post-traumatic stress disorder (PTSD) is uncertain. Methods: Six databases and other sources were searched through 30 July 2026 (PROSPERO CRD420261469444) for randomized controlled trials (RCTs) in adults with PTSD. Post-treatment symptom severity was synthesized as standardized mean differences (SMDs) in a random-effects network meta-analysis; trial-defined dropout as odds ratios (ORs) versus prolonged exposure (PE). Results: Of 6028 records, 166 reports (165 studies) were included; 48 RCTs (73 contrasts, 33 nodes) entered the symptom network; the others lacked compatible data or comparisons, and were synthesized narratively. VRET (5 RCTs, 209 participants; indirect evidence only) outperformed inactive control (SMD −1.20, 95% CI −2.07 to −0.34) and showed no statistically significant difference compared to PE (SMD 0.13, 95% CI −0.66 to 0.91) or other established therapies. Thirteen of the 19 nodes ranked above VRET were informed by a single trial. Across 12 RCTs (26 arms), dropout with VRET did not differ significantly from PE (OR 0.86, 95% CI 0.51–1.45), whereas written exposure therapy (WET) had lower dropout (OR 0.22, 95% CI 0.12–0.38). Heterogeneity was substantial (I2 = 77%), and global inconsistency was present. Excluding three influential trials lowered the WET P-score from 0.637 to 0.389, after which global inconsistency was no longer detected. Conclusions: VRET outperformed inactive control (low certainty) but showed no statistically significant differences from established trauma-focused therapies in efficacy or dropout; equivalence was not tested. The current evidence is insufficient to position VRET relative to first-line therapies, in either direction.