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

1. Post-traumatic Stress Disorder(PTSD)The management of PTSD in adults and children in primary and secondary care Clinical Guideline Published: March 2005

2. 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 2

3. 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 3

4. 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 4

5. 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 Treatment means that about 20% more people with PTSD recover Generally 33% remain symptomatic for 3 years or longer with greater risk of secondary problems 5

6. 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 6

7. 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 7

8. 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) 8

9. 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 9

10. 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 10

11. 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 11

12. 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 12

13. 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 13

14. 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 14

15. 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 15

16. 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 16

17. 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 17

18. 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 18

19. 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 What services are provided in your area? Create your own local services list! 19

20. 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 20

21. What should be audited? Key objectives: Patients involved in their care Treatment options are appropriate SO MEASURE………….. What isn’t 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 21

22. 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

23. 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 23

24. www.nice.org.uk 24