Update: PTSD/ASD Treatment Guidelines

GuidelinesResearch on traumatic stress disorders grows more voluminous and complex almost daily. While this is a very good thing, it does present an ongoing problem for treatment professionals. How are they to confidently summarize current knowledge so as to be assured of providing state-of-the-art care? A parallel problem exists for consumers of psychotherapy services: how are they to know that the treatment they are getting is the best available?

Treatment guideline summary recommendations, traditionally issued from time to time by major governmental agencies and professional organizations, address this need well[1]. Now we have a new and important guideline publication to guide professionals and consumers alike—the Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder, published late this summer by the Australian Centre for Posttraumatic Mental Health (ACPMH), a non-profit corporation originally devoted to trauma issues of military veterans but now also including the civilian population in their scope of concern.

Overview

An “update, revision and expansion of the original Guidelines” (ACPHC, 2013a, p. 2) published in 2007, the most significant change in this new edition of the Guidelines is the inclusion of recommendations for children and adolescents. Conveniently, it is published in four separate documents: a primary detailed statement of the Guidelines (ACPHC, 2013a), an extensive and lengthy set of appendices (ACPHC, 2013b), a special summary statement focused on children (ACPHC, 2013d), and an overall summary statement (ACPHC, 2013c). All are available for download in PDF format, which may be easily subjected to full-text search using common software. (See References below for details and download links.)

These non-prescriptive (ACPHC, 3013a, p. 2) Guidelines are derived from a systematic review of relevant literature, focusing on 24 specific research questions given to reviewers (ACPHC, 2013b, pp. 25-26). Recommendations are qualified by a grading system developed by the Australian National Health and Medical Research Council  (ACPHC, 3013a, p. 2):

  • Grade A: Available evidence can be trusted to guide practice.
  • Grade B: Available evidence can be trusted to guide practice in most situations.
  • Grade C: Available evidence provides some support for recommendation(s) but care should be taken in its application.
  • Grade D: Available evidence is weak and recommendation(s) must be applied with caution.

In cases where there was no research evidence for a recommendation, Consensus Points (CP) were assigned, based on the consensus opinion of the reviewers if such evidence had been expected, and Good Practice Points (GPP) in cases where no such evidence was expected to exist and none was looked for.

Treatment recommendations

Significantly stronger evidence was found for recommendations for adults than for children. In addition, it is important to realize that “posttraumatic mental health problems manifest in many different ways, and that ASD and PTSD are only two of the issues encountered by health professionals when helping individuals affected by traumatic events” (ACPHC, 2013c, p. 4).

Overall recommendations may be succinctly summarized: Do not medicate potentially traumatized children; do not use “psychological debriefing” at all. For adults, medication should not be used in preference to psychotherapy; in those cases where medication is indicated, the preferred choice is selective serotonin reuptake inhibitor (SSRI) antidepressants.

The single strongest recommendation (Grade A) is for trauma-focused cognitive behavioral therapy (TF-CBT) or eye-movement desensitization and reprocessing (EMDR), with TF-CBT alone being the recommendation for children.

Psychological interventions for adults

  1. Individuals exposed to potentially traumatizing events should not be offered a psychological “de-briefing” intervention [Grade B].
  2. Individuals who are displaying symptoms consistent with Acute Stress Disorder (ASD) or Posttraumatic Stress Disorder (PTSD) in the four weeks after exposure to potentially traumatizing events should be considered for individual TF-CBT, if this is indicated by a thorough clinical assessment [Grade C].
  3. Individuals diagnosed with PTSD should be given TF-CBT or EMDR [Grade A] (ACPMH, 2013a, p. 3).

Pharmacological interventions for adults

  1. Drug treatments should not be used as a blanket intervention for groups of people exposed to potentially traumatizing events [Grade D].
  2. Drug treatments should not be routinely used for individuals with ASD and early PTSD (within first 4 weeks of symptom emergence) [Grade C].
  3. For PTSD, drug treatments should not be used as a first treatment, in preference to TF-CBT pr EMDR [Grade B].
  4. For PTSD, when drug treatments are considered, the first choice should be SSRI antidepressants [Grade C].
  5. SSRI antidepressants should be considered in situations where an individual has not benefited from trauma focused psychological therapy, or has pre-existing conditions (details are given) which interfere with participation in such therapy [GPP] (ACPMH, 2013a, p. 4).

Psychological interventions for children and adolescents

  1. Children exposed to a potentially traumatic event should not be offered “psychological debriefing” [Grade B].
  2. Children of at least school age who have PTSD should be considered for developmentally appropriate TF-CBT [Grade C].
  3. Children exposed to a potentially traumatic event, with symptoms of PTSD, when exposed to the same event, should be considered for a school-based TF-CBT intervention to reduce symptoms [Grade C] (ACPMH, 2013a, p. 4).

Pharmacological interventions for children and adolescents

  1. Pharmacotherapy should not be considered as a blanket therapy for groups of children exposed to a potentially traumatic event [Grade D].
  2. Pharmacotherapy should not be given preference over TF-CBT for children with PTSD [Grade D].
  3. Pharmacotherapy should not be routinely used as an adjunct to TF-CBT for children with PTSD [Grade D]  (ACPMH, 2013a, p. 4).

Development Process and publication formats

The Guidelines are presented very attractively at the ACPMH website, hosted by the University of Melbourne. Four groups are addressed at the website—children, adolescents, adults, and mental health professionals. This largely reflects the focus of the Guidelines (ACPHC, 2013a, p. 1):

“The Guidelines have been designed to be used by: a) the range of general and mental health practitioners planning and providing treatment across clinical settings; b) people affected by trauma making decisions about their treatment; and c) funding bodies making service purchasing decisions.”

The quickest access to this large and significant work is the Guidelines Summary (ACPHC, 2013c). The main Guideline statement (ACPHC, 2013a) will be the focus of professionals, and some consumers; it’s well organized and easy to read into. For children and professionals, there is a brief summary “practitioner guide” statement (ACPHC, 2013d). Finally, for scholars, researchers, and those who wish to examine the basis for these guidelines, there is a separately published very substantial set of Appendices.

Of likely interest to professionals, Appendix 2 offers documentation of the process by which the Guidelines were developed. Key concepts relevant to this process are defined. Of particular interest is this statement concerning limitations of this effort:

“The Guidelines are principally limited to forms of distress consistent with the constructs of ASD and PTSD. They do not seek to address the full range of possible responses to traumatic exposure, including those known as Complex PTSD or Disorders of Extreme Stress Not Otherwise Specified (DESNOS). The original Guidelines were limited to adults; however, the revised version will also include children and adolescents.” (p. 4)

Then, concerning the question of who should actually use the Guidelines:

“There is insufficient evidence available in either the research or clinical practice literature to allow an authoritative specification of competencies required for particular interventions, and so the individual practitioner should be guided by his or her own professional code of conduct with regard to this issue.” (p. 5)

As it was a specific charge given to the Working Group that their recommendations be based on “a systematic review of the literature” (p. 13), the overwhelming bulk of the Appendices document is devoted to Appendix 3, which is the “Evidence Report” commissioned by the ACPMH and undertaken by the Adelaide Health Technology Assessment group, University of Adelaide. Addressed are ASD and PTSD, people “exposed to trauma”, school based interventions, psychological interventions, psychopharmacology, exercise and physical therapies, combined interventions, comorbidities, and “child-specific questions”. Appendix 3 has also several potentially useful sub-appendices. Appendix 5 (p. 592ff) is a complete specification of the DSM-5 Diagnostic Criteria for PTSD.

Summary

This is clearly a serious effort to guide treatment practices. That it is NOT focused solely on a military population is significant, given that, contrary to general public perception, most people with traumatic stress disorders are civilians. The explicitness of recommendations provides well-focused guidance for professionals concerned with providing best-practices care. The extensive and thoroughly documented accounting of the literature review upon which the recommendations are based is a model of transparency well-articulated thoughtfulness.

I find this 2-year large-scale effort fully deserving of respect by both professionals and the general services-consuming population. A large number of contributors, specialists in their fields working closely with each other and with many check and balances, produced what is offered here. In all regards, this is a definitive statement of best-practices treatment for traumatic stress disorders (ASD and PTSD) at this point in time.

Note

1. I am assembling a fairly complete list of such guidelines, and expect to have it completed soon after this present review is published.

References

Australian Centre for Posttraumatic Mental Health. Acute Stress Disorder & Posttraumatic Stress Disorder in Children & Adolescents: A Practitioner’s Guide to Treatment. Melbourne, Victoria, Australia: ACPMH, 2013. (7 pp) [download: http://guidelines.acpmh.unimelb.edu.au/__data/assets/pdf_file/0011/851672/ACPMH_Child_Practitioner_Guide.pdf]

—. Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder. Melbourne, Victoria, Australia: ACPMH, 2013a. (177 pp) [download: http://guidelines.acpmh.unimelb.edu.au/__data/assets/pdf_file/0008/851489/ACPMH_Full_ASD_PTSD_Guidelines.pdf]

—. Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder – Appendices. Melbourne, Victoria, Australia: ACPMH, 2013b. (596 pp) [download: http://guidelines.acpmh.unimelb.edu.au/__data/assets/pdf_file/0010/851473/ACPMH_Full_Guidelines_Appendices.pdf]

—. Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder: Guidelines Summary. Melbourne, Victoria, Australia: ACPMH, 2013c. (50 pp) [download: http://guidelines.acpmh.unimelb.edu.au/__data/assets/pdf_file/0011/851672/ACPMH_Child_Practitioner_Guide.pdf]

—. Australian Guidelines for the Treatment of Adults with Acute Stress Disorder & Posttraumatic Stress Disorder. Melbourne, Victoria, Australia: ACPMH, 2007.  Downloaded 2013.03.20 from http://www.acpmh.unimelb.edu.au/resources/resources-guidelines.html#1.

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