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

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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
• Review March 2009

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What is a NICE clinical guideline?

• Recommendations for good practice based on best
  available evidence
• DH document Standards for better health
  includes an expectation that organisations will
  work towards implementing Clinical Guidelines
• Healthcare Commission will monitor compliance
  with NICE guidance

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What is PTSD?

• A disorder that people may develop in response to
  traumatic events e.g. deliberate acts of
  interpersonal violence, severe accidents,
  disaster, or military action
• Criteria for a diagnosis of PTSD
• Exposed to a traumatic event
• Distressing re-experiencing of symptoms
• Avoidance of reminders of the event
• Arousal or numbing symptoms

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How common is PTSD?

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

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What does the guideline cover?

• The care provided by primary, secondary other
  healthcare professionals to
• Recognise, screen and diagnose the symptoms of
  PTSD
• Assess and coordinate care
• Treat all people with PTSD, including children
• Support families and carers

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What does the guideline not cover?

• Treating those people with Enduring personality
  changes after catastrophic experience
• DESNOS (complex-PTSD)
• Dissociative disorders
• Adjustment disorders

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What is the natural history of PTSD?
Traumatic Event
1 month
9 months
3 years
Generally 33 remain symptomatic for 3 years or
longer with greater risk of secondary problems
Many recover without treatment within
months/years of event (45-80 natural remission
at 9 months)
Usual onset of symptoms
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What is the natural history of PTSD?
Time elapsed since trauma (weeks) PTSD caseness GHQ gt 3 ()
0 60
1 51
2 31
4 17
13 8
26 12
52 8
GHQ General Health Questionnaire GHQ General Health Questionnaire
PTSD caseness of patients directly involved in
a raid over time. Data from Richards (1997) The
Prevention of PTSD after armed robbery the
impact of a training programme within Leeds
Permanent Building Society.
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What are the specific issues for children and
young people?

• Diagnostic categories same as adult
• But symptoms may differ in younger children (e.g.
  re-enacting, repetitive play)
• Offer Trauma Focussed-CBT for older children with
  severe PTSD, or those with chronic PTSD
• Drug treatments should not be routinely
  prescribed

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How to treat PTSD? (1)

• 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

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How to treat PTSD? (2)

• Offer brief treatments and longer term treatments
  appropriately
• Manage sleep disturbance
• Drug treatments
• - general use paroxetine or mirtazapine
• - specialist use amitriptyline or phenelzine
• Develop shared management approaches between
  primary and secondary care

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How to treat PTSD? (3)

• What else needs considering
• Co-morbid problems including drugs alcohol
• Barriers to treatment for refugees asylum
  seekers
• Managing people with PTSD as a result of a
  disaster

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What is EMDR?

• Eye movement desensitisation and reprocessing
• Based on theoretical model- dysfunctional
  intrusions, emotions, and physical sensations are
  due to improper storage of traumatic event in
  implicit memory
• Treatment involves eliciting specific targets to
  represent the traumatic event, the current
  triggers and future templates for appropriate
  function

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What are the implementation issues for clinicians?

• Move towards stepped- care will increase need for
  Trauma Focussed-CBT and EMDR
• Training implications
• Delivering care in primary-based settings
• Resource implications

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What are the implementation issues for managers?

• Dissemination
• Review of current practice
• Development and implementation of an action plan
• Monitoring and audit
• Review of progress

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What should managers include when conducting an
impact analysis?

• Managing the primary secondary care interface
• Joint working across the health and social care
  sectors
• Patient numbers and referral patterns
• Capacity scheduling and waiting times
• Resources released or required
• Workforce planning and training
• Current protocols and Disaster/Major Incident
  Plans

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How can cost be assessed locally?

• NICE is developing a costing tool for PTSD
• A national costing report and local costing
  templates will be available on the NICE website
  from May 2005

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What services are provided in your area?Create
your own local services list! See notes below.

• Consultant Psychiatrist
• Psychologist
• Mental Health Team
• Traumatic stress clinic
• CPN

• Voluntary organisations

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What should be audited?

• Possible Objectives
• Individuals with PTSD are involved in their care
• Treatment options are appropriately offered and
  provided
• Process
• Single audit all individuals with PTSD
• Or specific groups for e.g. people with chronic
  PTSD, a sample of patients from particular
  populations in primary care
• Measures
• Brief, single-session interventions (de-briefing)
• Watchful waiting
• Trauma focussed psychological treatment
• Trauma focussed CBT for older children
• Trauma focussed CBT for chronic PTSD in children
  and young people
• Drug treatments
• Disaster screening

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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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What other NICE guidance should be considered?

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

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Where is further information 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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In what format is the guideline available ?

• Full Guideline
• Produced by National Collaborating Centre
• Available electronically from NICE website
• Often 100 pages

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Quick reference guide

• As a minimum key priorities for implementation
• Where possible all recommendations
• Where appropriate algorithm
• Implementation statement
• Signposting for further information
• Available electronically
• Formats vary

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Quick Reference GuidePTSD
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Information for the public

• What the recommendations cover
• How guidelines are used in the NHS
• What you can expect from the NHS if you have PTSD
  
• Support and treatment if you have PTSD
• Questions you might want to ask about your care
  and treatment
• Glossary explanation of medical and technical
  words

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www.nice.org.uk
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