A Guide to Guidelines for the Treatment of PTSD and Related Conditions
Abstract
What are Clinical Practice Guidelines?
Clinical Practice Guidelines In PTSD
1. Clinical Practice Guideline for the Management of Post-Traumatic Stress VA/DoD Management of Post-Traumatic Stress Working Group, 2004 (http://www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp) |
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2. American Psychiatric Association Practice Guideline for the Treatment of Patients with ASD and PTSD American Psychiatric Association, 2004 (http://www.psychiatryonline.com/pracGuide/pracGuideTopic_11 .aspx) |
3. UK National Institute for Health and Clinical Excellence (NICE) Guidelines National Institute for Health and Clinical Excellence, 2005 (http://www.nice.org.uk/Guidance/CG26) |
4. Australian National Health and Medical Research Council (NHMRC) Guidelines Australian Centre for Posttraumatic Mental Health, 2007 (http://www.nhmrc.gov.au/publications/synopses/mh13syn.htm) |
5. The International Society for Traumatic Stress Studies (ISTSS) Guidelines Foa, Keane, Friedman, & Cohen, 2008 (www.istss.org;) |
6. American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for PTSD in Children and Adolescents American Academy of Child and Adolescent Psychiatry; Cohen et al., 2010 (http://www.aacap.org) |
7. Institute of Medicine. (2007). Treatment of PTSD: Assessment of the evidence. The National Academies Press, Washington, DC |
Methodologies
VA/DoD | APA | NICE | NHMRC | ISTSS | AACAP | IOM | |
---|---|---|---|---|---|---|---|
Country | United States | United States | United Kingdom | Australia | International | United States | United States |
Year | 2004 | 2004 | 2005 | 2007 | 2008 | 2009 | 2008 |
Constituency | For field personnel and health care workers assisting service members and veterans | Psychiatrists | Public mental health service staff who treat ASD & PTSD | Public and private mental health service who treat ASD & PTSD | Mental health clinicians who provide treatment for adults, adolescents, and children with PTSD | Child and adolescent psychiatrists | VA |
Developed by | Cross-disciplinary | Psychiatrists | Cross-disciplinary | Cross-disciplinary | Cross-disciplinary | Psychiatrists | Cross-disciplinary |
Nature of studies examined | RCTs, lower levels if no RCT available | RCTs, lower levels if no RCT available | RCTs | RCTs | All levels of studies | All levels of studies | High-level RCTs |
Who conducted the review | Subject matter experts within VA/DoD, with assistance and guidance from trauma experts | Psychiatrist subject matter experts | Independent evidence review specialists with assistance and guidance from trauma experts | Independent evidence review specialists with assistance and guidance from trauma experts | Experts in major fields of therapy and treatment modalities used for patients with PTSD | Subject matter experts | Independent IOM review |
Determination of the focus of the evidence review | Key questions determined at the outset | Literature search | Key questions determined at the outset | Key questions determined at the outset | Range of treatments applied in field | Literature search | Range of treatments applied in field |
Nature of evidence review conducted to determine intervention effectiveness | Expert review | Expert review | Meta-analysis | Meta-analysis | Expert review | Expert review | Meta-analysis |
Predetermination of what effect size would be considered significant | N | N | Y | Y | N | N | Y |
Weighting of effectiveness | Data and consensus | Data and consensus | Data | Data | Data and consensus | Data and consensus | Data |
Rating the Research Evidence
VA/DoD | APA | NICE | NHMRC | ISTSS | AACAP | IOM |
---|---|---|---|---|---|---|
[I] A least one properly done RCT | [A] Randomized double-blind clinical trial – A study of an intervention in which subjects are prospectively followed over time; there are treatment and control groups; subjects are randomly assigned to the two groups; both the subjects and the investigators are blind to the assignments | [I] Evidence obtained from a single randomized controlled trial or a meta-analysis of randomized controlled trials | [I] A systematic review of Level II studies | [A] Evidence is based on randomized, well-controlled clinical trials for individuals with PTSD | [RCT] Randomized, controlled trial is applied to studies in which subjects are randomly assigned to two or more treatment conditions | [I] Randomized controlled trial – Similar distribution of known confounders; validated PTSD outcome measure, double masking in pharmacotherapy studies, & assessor blinding or at least assessor independence in psychotherapy studies; no more than 40% loss to follow-up in any arm; loss to follow- up no greater than 15% absolute difference between groups; 10–40% missing outcome data acceptable depending on validity of missing data analytic method; rejection of LOCF if dropout >30% |
[II-1] Well- designed controlled trial without randomization | [A-] Randomized clinical trial; same as above but not double-blind | [IIa] Evidence obtained from at least one well-designed controlled study without randomization | [II] A randomized controlled trial | [B] Evidence is based on well-designed clinical studies, without randomization or placebo comparison for individuals with PTSD | [CT] Controlled trial is applied to studies in which subjects are nonrandomly assigned to two or more treatment conditions | [II-1] Controlled trial without randomization |
[II-2] Well-designed cohort or case-control analytic study | [B] Clinical trial - A prospective study in which an intervention is made and the results of that intervention are tracked longitudinally; study does not meet standards for a randomized clinical trial | [IIb] Evidence obtained from at least one other well-designed quasi- experimental study | [III-1] A pseudo- randomized controlled trial (e.g., alternate allocation or some other method) | [C] Evidence is based on service and naturalistic clinical studies, combined with clinical observations that are sufficiently compelling to warrant use of the treatment technique or follow the specific recommendation | [UT] Uncontrolled trial is applied to studies in which subjects are assigned to one treatment condition | [II-2]Cohort or case-control study |
[II-3] Multiple time series, dramatic results of uncontrolled experiment | [C] Cohort or longitudinal study – A study in which subjects are prospectively followed over time without any specific intervention | [III] Evidence obtained from well-designed, nonexperimental descriptive studies, such as comparative studies, correlation studies, and case studies | [III-2] A comparative study with concurrent controls (e.g., nonrandomized, experimental trial; cohort study; case-control study; interrupted time series with a control group) | [D] Evidence is based on long-standing and widespread clinical practice that has not been subjected to empirical tests in PTSD | [CS] Case series/report is applied to a case series or case report | [II-3] Time series or uncontrolled experiment |
[III] Opinion of respected authorities, case reports, and expert committees | [D] Control study – A study in which a group of patients and a group of control subjects are identified in the present and information about them is pursued retrospectively or backward in time | [IV] Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities | [III-3] A comparative study without concurrent controls (e.g., historical control study; two or more single arm studies; interrupted time series without a parallel control group) | [E] Evidence is based on long-standing practice by circumscribed groups of clinicians that has not been subjected to empirical tests in PTSD | [III] Opinion of respected authority, case report, and expert committee | |
[E] Review with secondary data analysis – A structured analytic review of existing data, e.g., a meta-analysis or a decision analysis | [IV] Case series with either posttest or pretest/posttest outcomes | [F] Evidence is based on recently developed treatment that has not been subjected to clinical or empirical tests in PTSD | ||||
[F] Review – A qualitative review and discussion of previously published literature without a quantitative synthesis of the data | [V] Evidence from expert committee or opinions of experts | |||||
[G] Other – Textbooks, expert opinion, case reports, and other reports not included above |
Clinical Practice Guideline Recommendations
VA/DoD | APA | NICE | NHMRC | ISTSS | AACAP | IOM |
---|---|---|---|---|---|---|
[A] A strong recommendation that the intervention is always indicated and acceptable | [I] Recommended with substantial clinical confidence | [A] At least one randomized controlled trial as part of a body of literature of overall good quality and consistency addressing the specifying recommendation (Evidence Level I) without extrapolation | [A] Body of evidence can be trusted to guide practice | Rating system based directly on A–F levels of evidence outlined in Table 3 | [MS] Minimal Standard – applied to recommendations that are based on rigorous empirical evidence (e.g., RCTs) and/or overwhelming clinical consensus. | [1] Evidence is sufficient to conclude the efficacy of X in the treatment of PTSD (a qualifier of magnitude may be added if appropriate) |
[B] A recommendation that the intervention may be useful/ effective | [II] Recommended with moderate clinical confidence | [B] Well-conducted clinical studies but no randomized clinical trial on the topic of recommendation (Evidence Levels II or III); or extrapolated from Level I evidence | [B] Body of evidence can be trusted to guide practice in most situations | [CG] Clinical Guideline – Applied to recommendations that are based on strong empirical evidence (e.g., non-RCTs) and/or strong clinical consensus | [2] Evidence is suggestive but not sufficient to conclude the efficacy of X in the treatment of PTSD (the committee may note inconsistencies in the data) | |
[C] A recommendation that the intervention maybe considered | [III] May be recommended on the basis of individual circumstances | [C] Expert committee reports or opinions and/or clinical experiences of respected authorities (Evidence Level IV) or extrapolated from Levels I or II evidence. This grading indicates that directly applicable clinical studies of good quality are absent or not readily available. | [C] Body of evidence provides some support for recommendation) but care should be taken in its application. | [OP] Option – Applied to recommendations that are acceptable based on emerging empirical evidence (e.g., uncontrolled trials or case series/reports) or clinical opinion, but lack strong empirical evidence and/or strong clinical consensus | [4] Evidence is suggestive that X treatment is ineffective in treating PTSD | |
[D] A recommendation that a procedure may be considered not useful/effective, or may be harmful | [GPP] Recommended good practice based on the clinical experience of the Guideline Development Group | [D] Body of evidence is weak and recommendation must be applied with caution. | [NE] Not Endorsed – Applied to practices that are known to be ineffective or contraindicated | [5] Evidence is suggestive that X treatment is harmful in the treatment of PTSD | ||
[I] Insufficient evidence to recommend for or against – the clinician will use clinical judgment | [GPP] Good practice point, based on expert consensus opinion, in the absence of an evidence base |
VA/DoD | APA | NICE | NHMRC | ISTSS adults | AACAP | IOM | ISTSS Children & adolescents | |
---|---|---|---|---|---|---|---|---|
Psychological treatment for PTSD 1st level rating | CT(A) Exposure (A) SIT (A) EMDR (A) | TFCBT (I) | TFCBT (A) EMDR (A) | TFCBT (A) EMDR in addition to in vivo exposure (A) | Exposure (A) CPT (A) CT (A) SIT (A) EMDR (A) Although reference on p624 “we can only recommend PE and CPT as first line treatments at this time” –although give “EMDR rating A” on p. 626 | TF psychological therapy TFCBT most evidence (MS) | Exposure (including CPT) | TFCBT |
2nd level rating | IRT (B) Psychodynamic psychotherapy (B) | EMDR (II) SIT (II) IRT (II) | Stress management (C) | Psychodynamic psychotherapy | EMDR | |||
Psychological treatment for ASD | Brief CBT (A) | TFCBT (II) | TFCBT (B) | TFCBT (A) | CBT (A) | CBT | ||
Recommendations on the initiation of therapy | Initiate treatment with both psychotherapy and pharmacotherapy | Initiate treatment with both psychotherapy and pharmacotherapy | Drug treatment should not be used as routine first line in preference to TF psychological therapy (A) | Drug treatment should not be used as routine first line in preference to TF psychological therapy (A) | Medication is a reasonable initial option if CBT is unavailable, not preferred by patient, or in combination with CBT. | |||
Pharmacotherapy for PTSD 1st level rating | SSRIs (A) | SSRIs (I) | SSRIs– General & specialist use (B) | Best evidence SSRIs and SNRIs SSRIs –sertraline, paroxetine, fluoxetine (A) SNRI- venlafaxine (A) TCAs (A) Mirtazapine (A) Nefazodone (A) MAO Is: phenelzine (A) Prazosin (A) | SSRIs (OP) | N/A | Fluoxetine Sertraline Citalopram (A/B) | |
2nd level rating | TCAs (B) MAOIs (B) | TCAs (II) MAOIs (II) | Paroxetine (B) Mirtazapine (B) general & mental health specialist use Amitriptyline (B) Phenelzine (B) mental health specialist use | Mirtazapine (B)TCAs (B) | Bupropion (C) Trazodone (C) | Clonidine (OP) Propranolol (OP) | Clonidine Guanfacine Propranolol (B,C,E) | |
Pharmacotherapy for ASD | Imipramine (B) | SSRIs (II) | Drug treatments for ASD not recommended (GPP) | N/A | ||||
Propranolol (C) | Other antide-pressants | |||||||
Initial responses /prevention | Recommend against PD as a viable means of reducing ASD or PTSD | PD or single session techniques not recommended | Single-session interventions that focus on the traumatic incident should not be routine practice when delivering services (A) | Structured psychological interventions such as psychological debriefing, should not be offered on a routine basis (C) | PD should not be used following traumatic events (A) | Debriefing not recommended | ||
Offer practical social and emotional support | Psychological first aid in which survivors are supported, immediate needs met and monitored over time (GPP) | Provision of practical, pragmatic psychological support and information (C) | ||||||
Mild & < 4 weeks, watchful waiting (C) | ||||||||
Screening for exposure | (Population exposed by definition) | Screen for recent or remote trauma exposure (I) | For patients presenting…ask whether or not they have been exposed to a traumatic experience (GPP) | For patients presenting…ask whether or not they have been exposed to a traumatic experience (GPP) | N/A | Psychiatric assessment should routinely include question about traumatic experiences and PTSD symptoms | N/A | N/A |
Screening for ASD and PTSD | Screen all patients for PTSD symptoms (C) | Assess for symptoms of ASD and PTSD (I) | For individuals at high risk of developing PTSD after a disaster, consideration should be given to the routine use of a brief screening instrument (C) | Service planning should consider the application of screening of individuals at high risk for PTSD after major disasters or incidents (GPP) |
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