Curative early psychosocial interventions: evidencebased

1
Curative early psychosocial interventions
evidence-based!

• Dr Jonathan I Bisson
• Clinical Reader in Psychiatry
• Cardiff University

2
Guideline recommendation 23

• Treatment with trauma-focused cognitive
  behavioural therapy for those affected who have
  an acute stress disorder or severe symptoms of
  post-traumatic stress disorder in the first month
  after a shocking experience

3
Wait and Target

• Traumatic stress symptoms within three months
• Acute stress disorder
• Acute PTSD
• Trauma-focused CBT
• Fifteen RCTs
• Individual 4-16 sessions (4 - 17 hours)
• Education, relaxation, imaginal exposure,
  cognitive restructuring and in vivo exposure

Roberts et al, 2008
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TFCBT vs Supportive counselling to treat ASD

• Clinician administered WMD -21.51 -30.24,
  -12.77
• Self report WMD -20.79
  -25.93, -15.66

Roberts et al, 2008
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TFCBT V waitlist acute distress from 2 weeks

• Clinician administered SMD -0.61 -1.10, -.13
• Self report SMD -0.84
  -1.72, 0.04

Roberts et al, 2008
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TFCBT v waitlist Acute PTSD

• Clinician administered SMD -1.22 -1.65, -0.78
• Self report SMD -1.68
  -2.34, -1.01

Roberts et al, 2008
7
Guideline recommendation 24

• The study group recommends that relaxation should
  be offered only as part of CBT, not as a
  (nontrauma-focused) intervention on its own

8
Relaxation
Psychological treatment for chronic PTSD versus
wait list

• Partner disagreement
• No evidence in first six weeks
• Absence of evidence is not evidence of no effect
• What if cant tolerate or access TFCBT?

SMD 95 CIs
9

• The European Network for Traumatic Stress
• http//www.tentsproject.eu/

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TENTS Delphi Process

• Recognizes the value of experts opinion,
  experience and intuition
• Allows use of limited information when full
  scientific knowledge is lacking
• 122 experts (106 responded)
• Three rounds
• After each round anonymous summary provided with
  reasons for judgments
• Convergence towards correct answer aimed for

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An Example of 2nd Round Question
12
Average Rating of All Questions
13
TENTS Guidance

• Other treatments should be available for
  individuals with acute post traumatic stress
  disorder when TF-CBT is not available or is not
  tolerated
• Evidence based interventions for individuals with
  other mental health difficulties should be
  available

14
Guideline recommendation 26

• In the event of sleep disorders as a result of
  the trauma, pharmacotherapy may be considered.
  For any drug treatment for sleep disorders,
  depressive disorders or anxiety disorders, the
  study group refers the reader to the existing
  guidelines.

15
Relative Risk of PTSD
95 CI 19
16
Shalev et al (2007)

• Prolonged exposure, cognitive therapy,
  escitalopram 10-20mg, placebo, wait list
  (bi-weekly telephone)
• 4220 screened, 1470 ve, 753 interviewed, 397
  invited for Rx, 289 randomised
• 152 agreed to any intervention, 118 to anything
  but SSRI, 19 SSRI cindd
• 12 SSRI non completers, 26 PE

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Shalev et al (2007)
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Early Pharmacological Interventions

• No convincing evidence
• Propranolol versus placebo (two studies)
• Gabapentin versus placebo (one study)
• Temazepam versus placebo (one study)
• Escitalopram versus placebo (one study)
• Limited evidence of benefit
• Hydrocortisone versus placebo (one study)

19
Guideline recommendation 27

• The study group recommends that the employer
  should offer counselling (to be carried out by a
  relief worker or trained volunteer) if a shocking
  event takes place at work.

20
Boscarino et al (2006)

• 1121 employed adults after 9/11
• Telephone interviews at 1 and 2 years
• 7 reported receipt of employer-sponsored,
  worksite crisis interventions (? timing) by
  mental health professionals (non worksite
  excluded)
• 1-3 sessions associated with positive outcomes,
  4 sessions excluded
• Sessions ranged from psychoeducation to anxiety
  management, 80 said they were positive

21
Employer counselling

• Partner agreement
• No evidence in first six weeks
• Absence of evidence is not evidence of no effect
• ? recommendation not based on evidence
• ? need to provide basic support and identify
  employees who require evidence based intervention

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Guideline recommendation 28

• The study group recommends treatment with
  trauma-focused cognitive behavioural therapy
  (CBT) for children, more than 7 years of age,
  with severe symptoms of acute post-traumatic
  stress and/or an acute stress disorder in the
  first month after a shocking event.
• Lacks evidence, consistent with NICE

23
Research Recommendations

• 25. Further studies into the effectiveness of
  EMDR as a curative early intervention in the
  first six weeks after stressful life events.
• 29. Further studies into the effectiveness of
  EMDR as an early curative intervention in
  children.
• 30. Further studies into pharmacological
  interventions in children.