Post-traumatic Stress Disorder(PTSD)

The management of PTSD in adults and children in primary and secondary care

Clinical GuidelinePublished: March 2005

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Further Info

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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Duration of symptoms for PTSD treated and untreated

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0 0.5 1 1.5 2 2.5 3.25 4 4.5 5.25 6 6.5 7.5

Duration of symptoms (years)

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Treatment

No treatment

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 doesn’t 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– Don’t 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?

• 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

Create your own local services list!

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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 careTreatment options are appropriateSO MEASURE…………..What isn’t recommended… Debriefing Ineffective psychological treatments Drug treatments NOT a first line treatmentWhat is recommended… Watchful waiting Trauma-focussed treatments (CBT and EMDR) for

adults and children

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Further Info

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 22

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What other NICE guidance should be considered?Published:• Anxiety December 2004• Depression December 2004• Self Harm July 2004In development:• Depression in children September 2005• Antenatal & postnatal mental health

February 2007

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Further Info

www.nice.org.uk

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