Dr Jonathan Leach, Professor Neil Greenberg, and Dr Odette Megnin-Viggars identify five key learning points from the updated NICE PTSD guideline

LEACH_Jonathan

Dr Jonathan Leach

Greenberg_Neil-edit

Professor Neil Greenberg

Megnin-Viggars Odette edit

Dr Odette Megnin‑Viggars

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Read this article to learn more about:

  • when to consider post-traumatic stress disorder (PTSD) in people who are presenting with related complaints
  • appropriate interventions for patients with PTSD
  • when and how to involve families and carers in discussions about PTSD.

Post-traumatic stress disorder (PTSD) is a mental health disorder characterised by intrusive psychiatric symptoms following exposure to severe trauma. PTSD can occur as a result of exposure to an extremely threatening or horrific event or series of events, such as threats to life, serious injury, death, or sexual violence to oneself or others.1 Repeated and/or extreme indirect exposure to trauma in the course of professional duties may also result in PTSD.1

A survey of the UK general population in 2014 found that 4.4% screened positive for PTSD in the month prior to being surveyed.2 A recent study in England and Wales found that just under 8% of the 2000 people surveyed experienced PTSD by the time they were 18 years old, and of these only one-fifth received support from mental health professionals.3 However, the risk of developing PTSD is higher in certain groups, such as in people who have been sexually assaulted (with multiple assaults increasing the risk),4 military veterans recently deployed in combat role (up to 17%),5 and ambulance personnel (15–23%).6

Timely diagnosis, addressing co-morbid mental health problems (often depression or substance misuse), and appropriate specialist referral are key to improving outcomes both for the patient and their family members, colleagues, and carers. NICE Guideline (NG) 116 on Post-traumatic stress disorder,7 published in December 2018, provides updated practical recommendations on the identification and treatment of people who have trauma-related mental health problems. This article highlights five key recommendations for primary care from the NICE guidance.

1. Keep PTSD in mind during consultations

People regularly consult their GP with psychological problems. Some people who appear to have anxiety and/or depression may in fact have PTSD. Establishing the possible presence of PTSD is important as there are effective treatments available. People with PTSD may also seek care for the physical health consequences of trauma, or present with a range of medically unexplained physical symptoms7—such as gastrointestinal difficulties, pain syndromes, or headaches.8 General functional difficulties, problems with relationships, and problem drinking may also be caused by PTSD.8 Therefore, it is worth enquiring whether people presenting with such problems have ever experienced a traumatic event, which may have been some time ago, after which their problems may have started.

For people with clinically important symptoms of PTSD presenting in primary care, GPs should take responsibility for assessment and initial coordination of care.7

Occasionally, a GP may see a child or young person following a potentially traumatic psychological event. Many of the symptoms in children are the same as in adults but NICE recommends not to rely solely upon the views of the carer or parent.7 Children with symptoms consistent with PTSD should be referred to relevant local services.

2. Trauma symptoms do not always suggest PTSD

Many people have transient symptoms after a traumatic event, and most people experiencing these symptoms will recover without the need for any professional intervention. Post-trauma symptoms may include poor sleep, rumination, and anxiety. Where symptoms last for days or weeks and do not substantially impair day-to-day function, they should be considered as a ‘normal reaction to an abnormal event’.7 However, persistent distress symptoms associated with functional impairment, if still present 1 month after an incident, should raise the possibility of a PTSD diagnosis. NICE recommends the active monitoring of people recently exposed to trauma.7 The signs and symptoms of PTSD as described by NICE are listed in Box 1.

Box 1: Signs and symptoms of post-traumatic stress disorder7

People with PTSD, including complex PTSD, may present with a range of symptoms associated with functional impairment, including:

  • re-experiencing [e.g. flashbacks and nightmares]
  • avoidance [of situations or cognitions that make any symptoms worse]
  • hyperarousal (including hypervigilance, anger, and irritability)
  • negative alterations in mood and thinking
  • emotional numbing
  • dissociation
  • emotional dysregulation
  • interpersonal difficulties or problems in relationships
  • negative self-perception (including feeling diminished, defeated, or worthless).

Complex PTSD may be diagnosed if all the diagnostic requirements for PTSD are met, in addition to the following characteristics:

  • severe and pervasive problems in affect regulation
  • persistent beliefs about oneself as diminished, defeated, or worthless, accompanied by deep and pervasive feelings of shame, guilt, or failure related to the traumatic event
  • persistent difficulties in sustaining relationships and in feeling close to others.

PTSD=post-traumatic stress disorder

© NICE 2018 Post-traumatic stress disorder. Available from www.nice.org.uk/guidance/ng116 All rights reserved. Subject to Notice of rightsNICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this publication.

3. Psychological interventions are preferred for PTSD

General practitioners can help people with PTSD by providing information and reassurance, and assisting with care—see Box 2.

For people with a formal diagnosis of PTSD, NG116 recommends offering psychological treatment, namely trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR). Alternatively, where the patient wishes, supported trauma-focused computerised CBT (a facilitated self-help intervention) should be considered.

From a GP’s perspective, it is important to note that NG116 recommends offering treatment to people with clinically important symptoms of PTSD, i.e. to those who are assessed as having PTSD on a validated scale, as indicated by baseline scores above the clinical threshold, but who do not necessarily have a diagnosis of PTSD.7

Military veterans can often access bespoke and quicker referral pathways such as the Transition, Intervention and Liaison (TIL) Service9 in England, which is commissioned to provide an initial assessment within 2 weeks. Details are available on the Armed forces healthcare page on the NHS website.10

For some people, alcohol or substance misuse can be a significant co-morbid problem; such difficulties should be medically assessed and relevant investigations arranged. NICE recommends that people are not excluded from PTSD treatment solely on the basis of co-morbid drug or alcohol misuse; the patient should be referred for specialist assessment and both substance misuse and PTSD treatment.

Box 2: Key considerations for primary care7

  • Provide information about common reactions to traumatic events and the benefits of active monitoring, self-care, and social support in the immediate aftermath of a traumatic event
  • Reassure those with probable PTSD that the condition is treatable
  • If PTSD is considered probable, refer for specialist treatment/assessment and provide appropriate information about the condition and possible treatment options
  • Be aware that some occupational groups such as military veterans or emergency services personnel might have different referral options available
  • Make adults aware that they can often self-refer to local mental health services
  • Consider whether carers/partners also need treatment or support
  • If needed, an SSRI such as sertraline or venlafaxine can be used in adults
  • Benzodiazepines should be avoided in patients with PTSD
  • Do not offer psychologically-focused debriefing in the immediate aftermath of a traumatic event.

PTSD=post-traumatic stress disorder; SSRI=selective serotonin reuptake inhibitor

4. Medication is not usually required

Within primary care, many patients with PTSD may not require medication and in broad terms CBT or EMDR are recommended first. However, selective serotonin reuptake inhibitors (SSRIs) such as sertraline or venlafaxine may be offered if the patient wishes. The use of other medications (e.g. antipsychotics) should only be initiated in specialist settings. It is important to note that the use of benzodiazepines should be avoided in patients with PTSD.7,11

5. Where appropriate, involve carers and parents

Symptoms of PTSD can be distressing and sometimes long-lasting. Consequently they may significantly impact upon carers and family members. It is often helpful to include carers and partners in any assessment/treatment discussions, subject to consent from the patient, and consideration should be given as to whether the carer or partner might need support or care themselves. Consider providing practical and emotional support and advice to family members and carers, which could include directing them to health or social services or peer support groups.7

If a traumatic event has affected an entire family, think about the impact on other family members, as the same event may cause multiple cases of PTSD; consider further assessment, support, and interventions for other family members suspected to have PTSD. For members of the same family who are experiencing PTSD as a result of the same event, think about what aspects of the treatment could be provided together, such as psychoeducation, alongside individual treatment.7

Conclusion

In general practice, healthcare professionals may see PTSD more often than they might expect. After a traumatic event, people should be actively monitored for the first few weeks. While anyone can develop PTSD, most individuals exposed to trauma will recover without the need for professional intervention. To help people recover, it is essential for GPs to have a potential diagnosis of PTSD in mind and to identify those who may be able to benefit from specialist care to support their recovery. Concurrent referral for any associated alcohol problems or substance misuse may also be needed.

Dr Jonathan Leach
General Practitioner, Davenal House Surgery Bromsgrove; NHS England Medical Director for Armed Forces and Veterans Health

Professor Neil Greenberg
Professor of Defence Mental Health, Academic Department of Military Mental Health, Kings College London

Dr Odette Megnin-Viggars
Senior systematic reviewer, Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London; National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London

Members of the guideline development group for NG116

References

  1. Phillips K, Craske M, Andrews G et al. Posttraumatic stress disorder. In: Schultz S, Kuhl E, editors. Diagnostic and statistical manual of mental disorders, 5th edition—DSM-5. Washington: American Psychiatric Association, 2013.
  2. Fear N, Bridges S, Hatch S et al. Posttraumatic stress disorder. In: McManus S, Bebbington P, Jenkins R, Brugha T, editors. Mental health and wellbeing in England: adult psychiatric morbidity survey 2014. Leeds: NHS Digital, 2016: 106–130. Available at: files.digital.nhs.uk/pdf/q/3/mental_health_and_wellbeing_in_england_full_report.pdf
  3. Lewis S, Arsenault L, Caspi A et al. The epidemiology of trauma and post-traumatic stress disorder in a representative cohort of young people in England and Wales. Lancet Psychiatry 2019;  (3): 247–256.
  4. Walsh K, Danielson C, McCauley J et al. National prevalence of PTSD among sexually revictimized adolescent, college and adult household-residing women. Arch Gen Psychiatry 2012; 69  (9): 935–942.
  5. Stevelink S, Jones M, Hull L et al. Mental health outcomes at the end of the British involvement in the Iraq and Afghanistan conflicts: a cohort study. Br J Psychiatry 2018; 213 (6): 690–697.
  6. Bennet P, Williams Y, Page N et al. Levels of mental health problems among UK emergency ambulance workers. Emerg Med J 2004; 21 (2): 235–236.
  7. NICE. Post-traumatic stress disorder. NICE Guideline 116. NICE, 2018. Available at: www.nice.org.uk/ng116
  8. NHS. Symptoms—post-traumatic stress disorder (PTSD). www.nhs.uk/conditions/post-traumatic-stress-disorder-ptsd/symptoms/ (accessed 27 February 2019).
  9. NHS Veterans’ Mental Health Transition, Intervention and Liaison Service. www.veteransservicelse.nhs.uk/ (accessed 26 February 2019).
  10. NHS. Armed forces healthcarewww.nhs.uk/using-the-nhs/military-healthcare (accessed 12 March 2019).
  11. NICE. Post-traumatic stress disorder. Evidence review F: pharmacological interventions for the prevention and treatment of PTSD in adults. NICE Guideline 116. NICE, 2018. Available at: www.nice.org.uk/guidance/ng116/evidence/evidence-review-f-pharmacological-interventions-for-the-prevention-and-treatment-of-ptsd-in-adults-pdf-6602621010