IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 Further Information Post-traumatic Stress Disorder (PTSD):

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Further Information

Post-traumatic Stress Disorder (PTSD):

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

Clinical GuidelinePublished: March 2005

Review: March 2009

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Further Information

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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Further Information

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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Further Information

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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Further Information

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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Further Information

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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Further Information

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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Further Information

What is the natural history of PTSD?

0

10

20

30

40

50

60

70

0 10 20 30 40 50 60

Time elapsed since trauma (weeks)

PT

SD

cas

enes

s (%

)

Time elapsed since trauma (weeks)

PTSD caseness GHQ > 3 (%)

0 60

1 51

2 31

4 17

13 8

26 12

52 8

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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Further Information

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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Further Information

How to treat PTSD? (1)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

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Further Information

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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Further Information

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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Further Information

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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Further Information

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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Further Information

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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Further Information

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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Further Information

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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Further Information

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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Further Information

What should be audited?Possible Objectives:

• Individuals with PTSD are involved in their care

• Treatment options are appropriately offered and providedProcess:

• 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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Further Information

What should be audited?

Key objectives:Patients involved in their careTreatment 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

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Further Information

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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Further Information

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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Further Information

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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Further Information

• As a minimum – key priorities for implementation

• Where possible – all recommendations

• Where appropriate – algorithm

• Implementation statement

• Signposting for further information

• Available electronically

• Formats vary

Quick reference guide

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Further Information

Quick Reference Guide:PTSD

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Further Information

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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Further Information

www.nice.org.uk

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