Posttraumatic Stress Disorder PTSD The management of PTSD in adults and children in primary and seco

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Post-traumatic Stress Disorder(PTSD)The
management of PTSD in adults and children in
primary and secondary care

• Clinical Guideline
• Published March 2005

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What is a NICE clinical guideline?

• Recommendations for good practice based on best
  available evidence
• DH Standards for better health expects
  organisations to implement clinical guidelines
• Healthcare Commission monitors compliance with
  NICE guidance

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What is PTSD?

• A disorder that develops in response to a
  stressful event or situation of exceptionally
  threatening or catastrophic nature e.g. assault,
  road accidents, disaster, rape
• Symptoms include
• re-experiencing symptoms (e.g. flashbacks,
  nightmares)
• avoidance of people or situations associated with
  the event
• emotional numbing
• hyperarousal symptoms

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How common is PTSD?

• Probability of developing PTSD after a traumatic
  event
• men 8 - 13
• women 20 - 30
• Annual prevalence
• 1.5 - 3
• Prevalence in PCT population of 170k
• 2.5k - 5k people
• Prevalence in GP practice of 5k
• 75 -150 people

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What is the natural course of PTSD?
Usual onset of symptoms a few days after the event
Many recover without treatment within
months/years of event (50 natural remission by 2
years), but some may have significant impairment
of social and occupational functioning
Generally 33 remain symptomatic for 3 years or
longer with greater risk of secondary problems
Treatment means that about 20 more people with
PTSD recover
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What does the guideline cover?

• The care provided by primary, secondary and other
  healthcare professionals to
• recognise, screen and diagnose PTSD
• assess and coordinate care
• treat all people with PTSD, including children
• support families and carers

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What is not covered?

• Adjustment disorders symptoms of significant
  trauma but doesnt meet criteria for PTSD
• Disorders such as
• dissociative disorders
• personality changes following trauma
• (because of diagnostic uncertainty and lack of
  agreement)
• Note many symptoms of these can be managed with
  interventions used in PTSD

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How to treat PTSD key messages

• Increased awareness and greater recognition of
  PTSD especially in primary care
• Increased provision of trauma focused
  psychological treatments
• Shift away from inappropriate use of medications
  and brief single session psychological treatments
  (debriefing)

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Immediate management of PTSD

• Psychological first aid
• Giving information and social support as soon as
  possible
• Avoid brief single session debriefing given to
  individuals alone following an event
• Watchful waiting if symptoms are moderate
  assess whether natural recovery occurs, review at
  one month
• Screen at risk groups
• Following disaster
• Refugees and asylum seekers

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Interventions for PTSD over time Within 3 months
of trauma

• Treat PTSD within 1 month if symptoms are severe
• Introduce trauma focused CBT by first month if
  symptoms persist

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Interventions for PTSD over time Beyond 3 months
of trauma

• Trauma-focused CBT or EMDR as first line
  treatment for people with more than a 3 month
  history of symptoms
• Drug treatments should not be used in routine
  care in preference to a trauma focused
  psychological therapy
• Where drug treatments are used
• general use paroxetine or mirtazapine
• specialist use amitriptyline or phenelzine

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Psychological treatments

• Interventions need to be focused on the trauma
  and structured
• Trauma-focused CBT- therapist helps the PTSD
  sufferer to
• Confront traumatic memories with less fear
• Modify misinterpretations which overestimate
  threat
• Develop skills to cope with stress

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Psychological treatments

• Eye motion desensitisation and reprocessing
  (EMDR) a structured trauma-focused
  psychological intervention
• PTSD sufferer is asked to recall an important
  aspect of the traumatic event
• The sufferer follows repetitive side to side
  movements, sounds or taps as the image is being
  focused on

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Challenges in treating PTSD

• Management of ongoing trauma eg domestic violence
• Ensure safety before starting treatment
• Comorbid drug and alcohol misuse
• If severe treat it first
• Severe depression
• Treat the depression first but most depression
  will get better

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Challenges in treating PTSD

• Ex-military personnel
• Be aware of possible increased risk in some
• Personality disorder
• Can still treat PTSD but may need to extend
  sessions
• Traumatic bereavement
• May complicate treatment

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What special issues are there for children and
young people?

• Diagnostic categories same as adult
• Important to talk to children directly and not
  rely solely on information from parents for
  diagnosis
• Symptoms may differ in younger children (e.g.
  re-enacting, repetitive play, emotional and
  behavioural disturbances)
• Offer trauma focused-CBT for children with PTSD
• Drug treatments should not be routinely
  prescribed

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What are the implementation actions for managers?

• Improve access to trauma focused psychological
  therapies
• Focus on the time to treatment not first
  assessment
• Shift to primary care
• Requires retraining some of the workforce
• Dont forget children

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How is cost assessed locally?

• NICE has developed a costing tool for PTSD
• A national costing report and local costing
  templates are available on the NICE website at
  www.nice.org.uk/costimpact

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What services are provided in your area?
Create your own local services list!

• Primary care based mental health services
• Psychological treatment services
• Community Mental Health Teams
• Traumatic stress services
• Social services
• Local authorities (occupational health)
• Non-statutory and voluntary organisations

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Developing implementation plans

• Prioritise recommendations locally
• Involve stakeholders including service users
• Assess current state compared to recommendations
  using audits
• Assess the impact of making the required changes
  to fill the gap cost, risk, resources
• Identify strategies to achieve this and a
  timescale to roll them out
• Identify barriers to implementation
• Evaluate implementation

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What should be audited?

• Key objectives
• Patients involved in their care
• Treatment options are appropriate
• SO MEASURE..
• What isnt recommended
• Debriefing
• Ineffective psychological treatments
• Drug treatments NOT a first line treatment
• What is recommended
• Watchful waiting
• Trauma-focussed treatments (CBT and EMDR) for
  adults and children

Audit against recommendations
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Where is the guideline available?

• Quick reference guide summary of recommendations
  for health professionals
• www.nice.org.uk/cg026quickrefguide
• NICE guideline
• www.nice.org.uk/cg026niceguideline
• Full guideline all of the evidence and rationale
  behind the recommendations
• www.rcpsych.ac.uk/publications
• Information for the public plain English version
  for sufferers, carers and the public
• www.nice.org.uk/cg026publicinfoenglish

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What other NICE guidance should be considered?

• Published
• Anxiety December 2004
• Depression December 2004
• Self Harm July 2004
• In development
• Depression in children September 2005
• Antenatal postnatal mental health
  February 2007

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www.nice.org.uk
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