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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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Presentation on theme: "Post-traumatic Stress Disorder (PTSD) The management of PTSD in adults and children in primary and secondary care Clinical Guideline Published: March 2005."— Presentation transcript:

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 IntroClinical background Treatment Implementation 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 2

3 IntroClinical background Treatment Implementation Further Info 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 IntroClinical background Treatment Implementation Further Info How common is PTSD? Probability of developing PTSD after a traumatic event: –men % –women % Annual prevalence: – % Prevalence in PCT population of 170k: –2.5k - 5k people Prevalence in GP practice of 5k: – people 4

5 IntroClinical background Treatment Implementation Further Info 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 5

6 IntroClinical background Treatment Implementation Further Info 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 IntroClinical background Treatment Implementation Further Info 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 7

8 IntroClinical background Treatment Implementation Further Info 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 IntroClinical background Treatment Implementation Further Info 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 IntroClinical background Treatment Implementation Further Info 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 IntroClinical background Treatment Implementation Further Info 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 IntroClinical background Treatment Implementation Further Info 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 IntroClinical background Treatment Implementation Further Info 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 IntroClinical background Treatment Implementation Further Info 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 IntroClinical background Treatment Implementation Further Info 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 IntroClinical background Treatment Implementation Further Info 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 IntroClinical background Treatment Implementation Further Info 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 17

18 IntroClinical background Treatment Implementation Further Info 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 18

19 IntroClinical background Treatment Implementation Further Info 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! 19

20 IntroClinical background Treatment Implementation Further Info 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 IntroClinical background Treatment Implementation Further Info 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 21

22 IntroClinical background Treatment Implementation Further Info Where is the guideline available? Quick reference guide: summary of recommendations for health professionals: –www.nice.org.uk/cg026quickrefguidewww.nice.org.uk/cg026quickrefguide NICE guideline –www.nice.org.uk/cg026niceguidelinewww.nice.org.uk/cg026niceguideline Full guideline: all of the evidence and rationale behind the recommendations: –www.rcpsych.ac.uk/publicationswww.rcpsych.ac.uk/publications Information for the public: plain English version for sufferers, carers and the public –www.nice.org.uk/cg026publicinfoenglishwww.nice.org.uk/cg026publicinfoenglish 22

23 IntroClinical background Treatment Implementation Further Info 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

24 IntroClinical background Treatment Implementation Further Info 24


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