1. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 Further Information 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 1

2. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 2

3. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 3

4. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 4

5. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 5

6. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 6

7. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 Further Information What is the natural history of PTSD? Traumatic Event 1 month9 months3 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 7

8. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 Further Information What is the natural history of PTSD? Time elapsed since trauma (weeks) PTSD caseness GHQ > 3 (%) 060 151 231 417 138 2612 528 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. 8

9. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 9

10. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 10

11. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 11

12. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 12

13. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 13

14. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 14

15. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 15

16. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 16

17. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 17

18. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 18

19. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 Further Information 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 19

20. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 Further Information 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 20

21. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 21

22. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 Further Information Where is further information available? Quick reference guide: summary of recommendations for health professionals: - www.nice.org.uk/cg026quickrefguide www.nice.org.uk/cg026quickrefguide NICE guideline - www.nice.org.uk/cg026niceguideline www.nice.org.uk/cg026niceguideline Full guideline: all of the evidence and rationale behind the recommendations: - www.rcpsych.ac.uk/publications www.rcpsych.ac.uk/publications Information for the public: plain English version for sufferers, carers and the public - www.nice.org.uk/cg026publicinfoenglish www.nice.org.uk/cg026publicinfoenglish 22

23. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 Further Information In what format is the guideline available ? Full Guideline Produced by National Collaborating Centre Available electronically from NICE website Often 100 + pages 23

24. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 24

25. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 Further Information Quick Reference Guide: PTSD 25

26. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 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 26

27. IntroClinical background Treatment Implementation 123456789101112131415161718192021222324252627 Further Information www.nice.org.uk 27